Appointment Request

Referral Information

If you have an insurance plan that requires a referral (typically HMO and POS plans) we require that the referral be registered with your insurance prior to scheduling the appointment.

Have you been seen in our office in the last 3 years?

Yes No

If you have been here within the last 3 years, please schedule a follow up appointment by clicking here to schedule. Do not hit submit. If you are a new patient or have not been seen within the last 3 years choose the NO option above and complete the form. Our staff will get you registered and reach out to schedule your appointment.

Preferred appointment day:

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred appointment time:

Morning

Afternoon

First Name

Last Name

Date of Birth

Sex

Male Female

Mailing Address

City

State

Zip

Home Phone

Cell Phone

Do you consent to receive automated phone calls?

Yes No

Do you consent to receiving text messages?

Yes No

You will not receive confirmation reminders if you choose no

Email address

Email required to complete online medical history for appointment.

Who referred you to us?

Who is your Primary Care Provider?

Insurance Name

Primary Insurance Member ID

including any letters

Primary Insurance Group Number

not all plans have a group number

Additional Insurance information

please provide secondary insurance name and member ID / group number, if applicable

Please briefly describe why you need to be seen

Your information will be encrypted.

ENT and Allergy, Inc.

Dr. Mark Andreozzi, Dr. Alejandro Vazquez, Dr. Amit Patel, Dr. Robert Risica

Warwick: (401) 921 - 5800, East Providence: (401) 435 - 5644
3520 Post Rd, Warwick, RI, 02886
400 Warren Ave., 2nd Floor, East Providence, RI, 02914