I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.

1. I, the undersigned, authorize and direct NJ Gastro, LLC staff members to provide any treatments deemed necessary, whether in person or virtually through telemedicine. I have read and understand this patient history form and certify that all information is correct.  I hereby accept responsibility for any amount not paid by my insurance.  

2. I hereby authorize NJ Gastro, LLC to release my medical information to the listed above.

3. I hereby authorize NJ gastro, LLC/Dr. Domenica Barritta/Dr. Eliezer Weiss, the use of electronic my signature to request my medical records for the purposes of continued medical care.

4. I have been informed that Dr. Barritta and Dr. Weiss have ownership interest in the Ironbound Endo-Surgical Center.

5. I have read and understand the information provided to me by NJ Gastro, LLC regarding the Patient's bill of rights and responsibilities.  

6. I understand and agree that if I fail to make any of the payments in a timely manner, I will be responsible for all costs of collecting monies owed to Ironbound Endo Surgical Center, P.C, NJ Gastro LLC, including collection fees, court costs, and attorney’s fees. The collection fee of 30% shall be due 30 days after the time that payment is due. If a payment is not made within 60 days from the time of the service, the credit card on file will be charged.