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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 --

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

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:

  • Colonoscopy

  • Upper Endoscopy

  • Flexible Sigmoidoscopy

  • Endoscopic Ultrasound

  • ERCP

  • Liver Biopsy

  • Other(as stated by doctor): ______________________________________.

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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