Registration - Family Internal Medicine

Nita Rastogi, MD – Family Internal Medicine

Welcome to Family Internal Medicine, the office of Dr. Nita Rastogi, MD. She offers primary care services for diagnosing and treating diseases, including addiction issues (alcohol and opioids), and aesthetic laser treatments (spider vein removal, photo facials, acne and acne scars, permanent hair removal). She ensures patients stay healthy and comply with treatments.

Dr. Rastogi’s practice accepts major private insurance and Medicare but not Medicaid. Cash-paying patients and those with high deductibles are welcome, and concierge medicine plans are available.

Note: All patients (new or existing) please complete the registration form before your appointment.

If you are not in the office, after submitting the registration form, you can complete the appointment form to book an appointment.

Name *

First

Last

Multiple Choice *

Male
Female

select one

Patient D.O.B. *

D.O.B. format mm/dd/year

Patient's Cell Phone *

Driver License # and State of License *

if none, write none

Email *

if none, write none

Patient's Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Name *

Relationship *

Contact Phone # *

Name of Pharmacy *

Give location address of Patent's Pharmacy

Pharmacy Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name of Primary Health Insurance Company *

If none, write self insured

Name of Person insured *

If self, write self

Patient's Relationship to the person insured *

If self or no onsurance, write self

Member ID # *

If self pay write None

Group # *

If self pay write None

Insurance Company Phone #

if known

Checkbox for consent *

By signing below, I authorize the use of my health information for medical consultation. I authorize direct payment to my physician. I permit a copy of this authorization to be used in place of the original. I understand that I am responsible for my bills, coinsurance, co-pays and deductibles. I understand that it is patient's responsibility to obtain verification requested by my physician including but not limited to labs, radiology, referrals, and any other medical related services or procedures.

Signature *

Clear Signature

sign by hand

Date *

Select Date

If patient is less than 18 years of age, Name of Parent *

if patient is 18 years or older, write N/A

If patient is less than 18 years of age, Signature of parent for payment Guarantee *

if patient is 18 years or older, write N/A

Thank you.

If you are not in the office and want to make an appointment, please select the Date and time, complete the form, and submit it.

Thank you.