New Patient Profile Form Step 1 of 4 25% Patient RegistrationAccountPatient Status*NewReturningDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Alternate PhoneEmail* Enter Email Confirm Email Email Alerts*Yes, please!No, thank you. DemographicsGender*MaleFemaleMarital Status*SingleMarriedDivorcedWidowedEthnicity*Decline to RespondCentral AmericanCubanDominicanHispanic or LatinLatin AmericanMexicanNot Hispanic or LatinPuerto RicanSouth AmericanSpaniardRace*Decline to RespondWhite/CaucasianAfricanAfrican AmericanAlaskan NativeAmerican IndianArabAsianAsian IndianBahamianBarbadianBhutaneseBlackBurmeseCambodianChineseDominican IslanderDominicanEuropeanFilipinoHaitianHmongIndonesianIwo JimanJamaicanJapaneseKoreanLaotianMadagascarMalaysianMelanasianMirconesianMiddle EasternNative HawaiianNepaleseNorth AfricanOkinawanOther Pacific IslanderPakistaniSingaporeanSri LankenTaiwaneseThaiTobogoanTrinidadianVietnameseWest IndianPreferred Language*African LanguagesAmerican Sign LanguageArabicArmenianChineseEnglishFrenchFrench CreoleGermanGreekGujaratiHebrewHindiHmongHungarianItalianJapaneseKoreanLaotianMon-khmer, CambodianNavajoNepaliPersianPolishPortugueseRussianSerbo-CroatianSpanishTagalogThaiUrduVietnameseYiddishProviding 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. EmploymentEmployment Status:*Full-TimePart-TimeUnemployedEmployer NameEmployer PhoneEmergency Contacts & Permissible PersonsFirst Eye Associates would like all patients to list at least one emergency contact for their own benefit. Additionally, if you have any persons (relatives, friends, assistants) that you wish to have permission (permissible person) to speak about your information with us, you may select that here...as well as the level of appropriateness.Name First Last PhoneContact TypeEmergency OnlyPermissible OnlyEmergency and PermissibleContact Permissible LevelScheduling OnlyAccount Balances OnlyScheduling and Accounts OnlyHealth InformationAll of the AboveThis person isNot a guarantor for my insuranceGuarantor for my primary insuranceGuarantor for my secondary insuranceAnother Contact?YesNoName First Last PhoneContact TypeEmergency OnlyPermissible OnlyEmergency and PermissibleContact Permissible LevelScheduling OnlyAccount Balances OnlyScheduling and Accounts OnlyHealth InformationAll of the AboveThis person isNot a guarantor for my insuranceGuarantor for my primary insuranceGuarantor for my secondary insurance Insurance InformationPrimary Insurance Co.Policy NumberGroup NumberGroup NameSecondary Insurance Co.Policy NumberGroup NumberGroup NameCommentsThis field is for validation purposes and should be left unchanged.