West Omaha Family Physicians, P.C.
17030 Lakeside Hills Plaza, Suite 130, Omaha, NE 68130  •  Phone: (402) 758-5150  •  Fax: (402) 758-5158

Step 1 of 3. Instructions
Please complete the four information sections below: Patient Information, Spouse or Parents Information, Emergency Contact Information, Physician Information, and Protected Health Information. After entering the patient information, select the Step 2 Review button at the bottom of this page to continue.

Note, required information is denoted with an asterisks (*).

Section 1. Patient Information (* denotes required information)
Please enter the demographic and contact information for the patient visiting West Omaha Family Physicians, P.C. below.

Patient's Demographic Information
Last name: *
First name: *
Middle initial:  
 
Date of birth: *
//(mm/dd/yyyy)
Gender: * Male
Female
Marital status: * Single
Married
Social security number: *
--(###-##-####)
 
Patient's Contact Information
Address: *
   
City: *
State: *
Zip code: *
 
Home phone: *
()-(###-###-####)
Cell phone:  
()-(###-###-####)
 
Patient's Employer Information   (check if not applicable)
Employer name: *
Occupation: *
Work phone: *
()-(###-###-####)

Section 2. Spouse or Parents Information (* denotes required information)
Please enter the demographic and contact information for the spouse, if married, or the parents of the patient, if the patient is a child, for the patient visiting West Omaha Family Physicians, P.C. below.

Spouse or Parents Information not applicable.


Section 3. Emergency Contact Information (* denotes required information)
Please enter the emergency contact person for the patient visiting West Omaha Family Physicians, P.C. below.

Emergency's Demographic Information
Last name: *
First name: *
Middle initial:  
 
Relationship to patient: *
 
Emergency's Contact Information   (check if same as patient)
Address: *
   
City: *
State: *
Zip code: *
 
Contact phone: *
()-(###-###-####)

Section 4. Physician Information (* denotes required information)
Please enter the physican referring the patient visiting West Omaha Family Physicians, P.C., if applicable, below.

Referring Physican's Information (if applicable)
Last name:  
First name:  
Middle initial:  
 
Referring Physican's Location Information (if applicable)
City:  
State:  

Section 5. Protected Health Information (* denotes required information)
Please identify the person(s) with whom the patient's Protected Health Information may be released to and their relationship to the patient.

Protected Health Information May Be Released To Person 1 (if applicable)
Last name:  
First name:  
Middle initial:  
 
Relationship to patient:  
 
Protected Health Information May Be Released To Person 2 (if applicable)
Last name:  
First name:  
Middle initial:  
 
Relationship to patient:  

Select the Step 2 Review button to review the entered patient information and continue to Step 2 of 3 in the registration process. If you have questions or comments about this form or about West Omaha Family Physicians, P.C., please call (402) 758-5150.