Patient Information Form

Complete Cure Medical

Please correct the errors described below.


Please provide the receptionist with your insurance card(s).

  1. I hereby assign my insurance benefits to be paid directly toaisal Nagarwala, MD / Council of Complete Cure Medical
  2. I also authorize the physician to release any information requested by my insurance company.
  3. I understand that the above information concerning my condition will be used for filing insurance reports.
  4. I certify all the information to be true and complete.
  5. I understand I am financially responsible for all charges not covered by my insurance company.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

History Form

List the medications that you are taking (include OTC meds and supplements)

Add another medication.

If YES, please list:

Add another allergy

List your past surgeries:

Add another surgery

Review of Systems

Past Medical History

Family History

If applicable, check which family member has the following conditions:

Social History

Your information will be encrypted.