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Paparella Ear, Head & Neck Institute respects your confidential information and has taken reasonable steps to protect your information from unauthorized interception and use. The risk, however, of unauthorized use of electronically transmitted information cannot be entirely eliminated.

We will respond to your request within 2 hours of receipt during normal business hours, Monday-Friday, between 8 a.m. and 5 p.m.

By clicking on the "Submit" button below, you agree to the terms of this Disclaimer. If you do not agree to the terms of this Disclaimer, please call us to schedule your appointment at 1-866-316-0769 or 612-339-2836 during normal business hours, 8 a.m. – 5 p.m., Monday through Friday. Thank you for scheduling with Paparella Ear, Head & Neck Institute.

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Patient Registration Form

* Indicates required information

* First Name:

* Middle Initial:

* Last Name:

* Date of Birth:

/ / (mm/dd/yyyy)

* Gender: :

Male Female

* Address:

* City:

* State:

* Zip Code:

* Preferred Phone Number:

Home Cell Work

Optional Phone Number:

Home Cell Work

Email:

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Patient Medical Information

Please indicate the reason for the appointment.

Diagnosis or Illness:

 

Additional Medical Information:

 

* Clinic Location:

Maple Grove
Minneapolis


Appointment Information

We will make every effort to accommodate your request but may need to offer a second option.

* Providers:

Michael Paparella, MD
Mike Puricelli, MD
Joshua Yorgason, MD
Katherine Awoyinka, AuD, CCC-A
Joseph Neve, AuD, CCC-A
Jessica Connolly Russow, AuD, CCC-A
Carol Klitzke, MS, CCC/SLP

* Preferred Appointment Time :

8 - 9:00 a.m.
9 - 10:00 a.m.
10 - 11:00 a.m.
11:00 a.m. -
Noon
1 - 2:00 p.m.
2 - 3:00 p.m.
3 - 4:00 p.m.
4 - 5:00 p.m.
5 - 6:00 p.m.

Additional Appointment Information:

 


Insurance Information

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Primary Group #:

Secondary Insurance:

Secondary Policy ID #:

Secondary Group ID#:


Referral Information

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Self
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Other Healthcare Provider

If referred by another healthcare provider, please complete the following:

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© 2017. All Rights Reserved. Paparella Ear Head & Neck Institute, PA
Paparella Minneapolis
Riverside Park Plaza
701 25th Avenue South
Suite 200
Minneapolis, MN 55454
866-316-0769 toll-free
612-339-2836
Paparella Maple Grove
Arbor Lakes Medical Bldg
12000 Elm Creek Blvd
Suite 140
Maple Grove, MN 55369
866-316-0769 toll-free
612-339-2836