Patient Registration

First Name

Date of Birth

Social Security Number

e-mail Address

MIddle Initial

Last Name

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 secure@omahainsomnia.com, a HIPAA-compliant domain. I understand that Omaha Insomnia and Psychiatric Services will never release my information to a third party without my consent.