New Patient Form

Contact us

800.393.8257

2101 Burlington Beach Rd

Valparaiso, Indiana 46383

Medical Arts Center

297 W Franciscan Ln, Ste 101

Crown Point, Indiana 46307

Franciscan Physicians Hospital

701 Superior Ave, Ste A

Munster, Indiana 46321

New Patient Form

You can print and complete the following 5-page form, and bring it with you when you come in for your appointment.

Patient Registration Form & Medical History (PDF) >

Valparaiso 219.462.0311

Crown Point 219.662.2563

Munster 219.934.0583

LTF Eye Clinic Locations

Eye Doctors

Valparaiso Eye Clinic

Myron Lewyckyj, MD

Richard Ireland, OD, FAAO

Crown Point Eye Clinic

Nandini Menon, MD

Colin Jack, OD

Munster Eye Clinic

Daniel Taglia, MD

Caterina Komyatte, OD

Anusha Vasamsetti, MD

Nikole Schilling, OD

Sarah Tsagris (Baker), OD

SaaS provided by Digital Destination LLC & jmmago.com

Home

Location
Valparaiso
Crown Point
Munster
Services
Cataracts
Contact Lenses
CORNEAL TRANSPLANTS
Diabetes Services
Dry Eye
Eye Surgery
Eyelid Surgery
Glaucoma
LASIK
Macular Degeneration
Ocular Rosacea
Pediatric Eye Exam
Pink Red Eye Treatment
Routine Eye Care
VITREOUS DETACHMENT
Info
FAQ
Insurance
- Patient Information
  Eye Surgery Forms
  New Patient Form
Resources
Optical Shops
Contact Lens Brands
Eyewear Lines
Order Contact
- ZEISS Vision Care
  PhotoFusion by ZEISS
  ZEISS Custom Lenses
  ZEISS Custom Lens Coatings
  ZEISS New DriveSafe Lens Technology
About Us
- Ophthalmologists
  Myron Lewyckyj, MD
  Nandini Menon, MD
  Daniel Taglia, MD
  Anusha Vasamsetti, MD
- Optometrists
  - Richard Ireland, OD, FAAO
    LOW VISION
  Colin Jack, OD
  Caterina Komyatte, OD
  Nikole Schilling, OD
  Sarah Tsagris (Baker), OD

Español

Valparaiso 219.462.0311

Crown Point 219.662.2563

Munster 219.934.0583

Contact us

Home

Location
Valparaiso
Crown Point
Munster
Info
FAQ
Insurance
- Patient Information
  Eye Surgery Forms
  New Patient Form
Resources
Services
Cataracts
Contact Lenses
CORNEAL TRANSPLANTS
Diabetes Services
Dry Eye
Eye Surgery
Eyelid Surgery
Glaucoma
LASIK
Macular Degeneration
Ocular Rosacea
Pediatric Eye Exam
Pink Red Eye Treatment
Routine Eye Care
VITREOUS DETACHMENT
Optical Shops
Contact Lens Brands
Eyewear Lines
Order Contact
- ZEISS Vision Care
  PhotoFusion by ZEISS
  ZEISS Custom Lenses
  ZEISS Custom Lens Coatings
  ZEISS New DriveSafe Lens Technology
About Us
- Ophthalmologists
  Myron Lewyckyj, MD
  Nandini Menon, MD
  Daniel Taglia, MD
  Anusha Vasamsetti, MD
- Optometrists
  - Richard Ireland, OD, FAAO
    LOW VISION
  Colin Jack, OD
  Caterina Komyatte, OD
  Nikole Schilling, OD
  Sarah Tsagris (Baker), OD

Español

SaaS provided by
Digital Destination LLC & jmmago.com