Name: Office Information
Address: 8111 Dodge St., Omaha, NE, 68114, US
Telephone: +1 402-354-8111
Price range: Call for pricing options

Patient Registration
Account
Patient Status*
- New
- Returning
Date of Birth*
Name
Prefix First Middle Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Alternate Phone
Email*
Enter Email Confirm Email
Email Alerts*
- Yes, please!
- No, thank you.

Demographics
Gender*
- Male
- Female
Marital Status*
- Single
- Married
- Divorced
- Widowed
Ethnicity*
Race*
Preferred Language*
Providing this information allows First Eye Associates to better understand the populations it serves, measure disparities in care within our organization, initiate programs to improve the quality of care, and provide a patient centric care structure.

Something as simple as providing a preferred language allows us to provide any number of communications, from appointment reminders to post-operative surgery instructions, in a format easily understood by the patient.

Insurance Information
Primary Insurance Co.
Policy Number
Group Number
Group Name
Secondary Insurance Co.
Policy Number
Group Number
Group Name
Comments
This field is for validation purposes and should be left unchanged.

New Patient Profile Form

Step 1 of 4

Patient Registration

Demographics

Employment

Emergency Contacts & Permissible Persons

Insurance Information

Eye Resources

Contact Lenses

Lenses & Frames

Eye & Health Disease

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