Eye Care Provider Referral Form

"*" indicates required fields

Patient First Name*

Patient Last Name*

Address*

Street Address City State ZIP Code

Phone*

Date of Birth*

Gender

Patient Insurance*

Referring Physician

Reason for Referral

Referring Provider Name

Clinic Name

Clinic Phone Number

Interpreter Needed

Yes

Which language?

Please include a copy of most recent exam notes and fax to 651-251-5950

Comments

This field is for validation purposes and should be left unchanged.

Open Cities Health Center

We’re here to help you live your healthiest, happiest life.

Dunlap Clinic

409 North Dunlap St.
St. Paul, MN 55104

HOURS
MWTHF: 8am – 5pm
Tuesdays: 8am – 8pm

North End Clinic

916 Rice St.
St. Paul, MN 55117

HOURS
Monday – Friday: 8am – 5pm

Health Services

* Dental services are available Monday – Friday, 8am – 5pm at our Dunlap and North End Clinic

About Us

Open Cities Health Center is a FTCA deemed Facility.

This health center receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.