At Omaha Primary Eye Care, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.

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New Patient Health History Form

Patient Information


Patient Name:



Zip Code:


Phone Number:

Email Address:

Date of birth

Social Security Number

Primary Care Physician or NONE:

Endocrinologist (if applicable):

Employer and Occupation OR School and Grade:

Person responsible for account, if someone other than yourself:

We are required by insurance companies to ask for the following information. We would appreciate your answers so we can avoid payment penalties from insurers.

Preferred Language:




Do you have any allergies to medications? Please list:

Do you have any general allergies? Please list:

Are you currently taking any medications? Please list or bring a copy with you:

What brings you to our office today?

Have you ever been diagnosed with any of the following conditions? (Please check)

Are you having any of the following eye concerns? (Please check)

Are you having any of the following vision concerns? (Please check)

Do you have medical conditions pertaining to the following body systems? (Please check)

Do you drink alcohol? (Please circle)

Do you smoke? (Please circle)

Have any of your immediate family members had any of the following conditions? (Please circle)

Authorization for the Disclosure of Medical Information

I hereby authorize Omaha Primary Eye Care to disclose any medical information.

Such information is to be faxed to Omaha Primary Eye Care PC at 4023830780 or mailed to: Omaha Primary Eye Care, PC 14607 W. Center Road Omaha, NE 68144.

This authorization will terminate thirty days from the date noted below.

I understand that if this information is disclosed to a third party, the information may be re-disclosed by the person or entity that received the information and may no longer be protected by federal privacy regulations.

Payment Authorization
We ask that the patient's portion of the billing be paid at the time services are rendered. Payment from your insurance company is to be paid directly to Omaha Primary Eye Care. I understand that the insurance benefits I receive are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed. The undersigned accepts full responsibility for any bill incurred at this office that is not covered or paid for by their insurance company. Accounts 90 days old are subject to collection fees. There will be a service charge on all returned checks. My signature below acknowledges that I have read and understand the previous statements and that I have had the opportunity to receive/review OPEC's Privacy Policy Notice.

New Patient Health History Form – Required

Please complete this form as it lets us know the history and current state of your health. Let us know what questions, concerns, and goals your have regarding your eye health or vision on the form.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.

  • Download the necessary form(s), print it out and fill in the required information.

  • Fax us your printed and completed form(s) or bring it with you to your appointment.