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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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Ambulatory
Surgical Center Suite
-- CANCELLATION
FEE --
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Patient : Please read
the following and sign at
the bottom of the page. |
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There will be a $50.00 Cancellation fee charged
directly to you, the patient, if a procedure in
the office or hospital is cancelled with less than
72 hours notice of appointment date.
Procedures include:
Please sign below acknowledging
that you agree to this prior to scheduling the
procedure.
If you do not agree to sign this, the test cannot
be scheduled. |
Patient's Signature:
______________________________________________________________
Date: _______ / ______ / 20____
Witness of Signature:
_____________________________________________________________
Date: _______ / ______ / 20____
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Copyright © 2005 Gastroenterology Consultants of South Jersey, P.C. All Rights Reserved.
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