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Gastroenterology Consultants of South Jersey
Amherst Commons, Building A, Suite 2
693 Main Street, Lumberton, New Jersey
Telephone: (609) 265-1700    Visit us Online: www.GCSJ.org

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-- CANCELLATION FEE POLICY --
Missed Appointments

Patient : Please read the following and sign at the bottom of the page.

We have initiated a cancellation fee for missed office appointments or procedure visits to ensure that patients are seen in the office as quickly as possible. When patients miss appointments, we miss opportunities to see patients as quickly as we can.

Office Visits
If a patient misses an appointment and does not give 48 hours notification, then the patient will be charged $25.00. The patient will not be seen again in the office until this bill is paid. We do recognize that unforeseen events can occur. The Doctor on a case-by-case basis can waive the fee if there is a valid emergency. After the third missed office visit, the Doctor may ask the patient to leave the practice and seek their care elsewhere after a 30 day transition period. Visits include: Office Visits, Breath Test and Capsule Study.

Procedure Visits
There will be a $50.00 Cancellation Fee charged directly to the patient if a procedure is cancelled with less than 72 hours notice of an appointment date. This includes procedures done at the office or the hospital. Procedures include: Colonoscopy, Upper Endoscopy and Flexible Sigmoidoscopy.

I acknowledge that I have reviewed and read the above policy and understand my responsibilities and obligations for any missed appointments.

Print Patient Name: ______________________________________________________________________

Patient Signature: ________________________________________________________________________

Account #: ____________________________      Date: _______ / ______ / 20______

 

Witness of Signature: _____________________________________________________________

Date: _______ / ______ / 20____

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Copyright 2006 Gastroenterology Consultants of South Jersey, P.C. All Rights Reserved.
 

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