Robert D. Russo M.D. and Associates Radiology

Appointment Request Form

Please fill out the below form with necessary information that is available to you. Please be sure to fill out your name, phone number where you can be reached and email address so that we may quickly contact you. Our Scheduling Department will contact you within 24 hours to schedule an appointment. If you prefer to talk to a Scheduler directly please call us at 1-203-683-XRAY (9729). On the day of your scheduled appointment please bring the script/form your doctor gave you.

Name * First Last
Date of Birth * MM / DD / YYYY
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email Address *

Email information is for Robert D. Russo MD & Associates Radiology use only; it will not be shared with anyone.
Phone Number * ### - ### - ####
Please use the phone number that is most convienent for us to contact you.
Appointment Information

Please insert necessary information so we can schedule you for the appropriate exam at your preferred time.
Insurance Company *

Please insert the name of your Health Insurance Carrier
Policy Number

Your Policy Number can also be considered the ID# on some cards.
Referring Physician's Name *

Please put the name of the Doctor who is sending you for this exam.
Exam to be Scheduled

What type of exam does your Doctor want you to have?
Preferred Day for Exam

Please pick which day of the week works best with your schedules. For more office hour information please refer back to the locations page.
Preferred timeframe for exam

Please select a time-frame for when you would like your exam scheduled.
Do Not Fill This Out

Robert D. Russo M.D. and Associates Radiology

Appointment Information