Date of Birth
Social Security Number
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 firstname.lastname@example.org, a HIPAA-compliant domain. I understand that Omaha Insomnia and Psychiatric Services will never release my information to a third party without my consent.