Click to Print

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

Click to Return

NOTICE OF PRIVACY PRACTICES

RECEIPT OF NOTICE OF PRIVACY PRACTICES

WRITTEN ACKNOWLEDGEMENT FORM.

 

I, ___________________________________________, have received a copy of the
Gastroenterology Consultants of South Jersey's Notice of Privacy Practices.

 

Patient's Signature: ______________________________________________________________

Date: _______ / ______ / 20____

Please sign in office, witnessed by GCSJ staff. Thank you!

 

 

[Print this Page]

[Return to Previous Page]

 Information was printed from http://www.GCSJ.org
Copyright 2005 Gastroenterology Consultants of South Jersey, P.C. All Rights Reserved.
 

Site designed, developed and maintained by WebWiser.com