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A Digestive Wellness Center

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AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION

Patient's First Name

Last Name

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I HEREBY AUTHORIZE AND REQUEST TO PROVIDE MY MEDICAL RECORDS TO NJ GASTRO, LLC / DR. DOMENICA BARRITTA/ DR. ELIEZER WEISS FOR THE PURPOSES OF CONTINUED MEDICAL CARE.

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Date

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LOCATIONS

79 Hudson St, Suite 301

Hoboken, NJ 07030

24 Merchant St

Newark, NJ 07105

327 60th St

West New York, NJ 07093

HOURS

Monday - Friday: 9:00am – 5:00pm

E-mail: njgastrollc.app@gmail.com

T. 973-645-0000

F. 973-645-0001

© 2019 by NJ GASTRO

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