Registration - Family Internal Medicine

Nita Rastogi, MD – Family Internal Medicine

Note: All patients (new or existing) please complete the registration form before your appointment. After submitting the registration form, please make your office appointment from the Book Appointment Tab.

Registration Form

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

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, radio;ogy, referrals, and any other medical related services or procedures.

write your name

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.