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Patient Registration

First Name

MIddle Initial

Last Name

Date of Birth

Social Security Number

e-mail Address


Phone - Best Contact

Contact us on 

New patients referral line: 

(402) 452-3279 (Monday to Thursday)

(402) 991-9630 (Friday and Saturday evening)

I attest that the above information is accurate and will exactly match the information provided at the time of service. Furthermore, I agree to receive e-mail notifications from, a HIPAA-compliant domain. I understand that Omaha Insomnia and Psychiatric Services will never release my information to a third party without my consent. 

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