I have been given information on privacy, patient rights and advanced directives by my provider and I understand that my provider is one of the owners of Garden State Endoscopy & Surgery Center.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Please provide your insurance card(s) and picture I.D. and proof of address to the receptionist. Than you very much.
Patient confidentiality is a prime concern in this office. Please indicate below with whom our office can or cannot leave a message.
Due to confidentiality regulations, should a family member, friend, or relative contact our office, we are not liberty to discuss your situation unless we have a permission from you - the patient.
Add Children &/ or Significant Others
I verify that the list is complete and accurate to the best of my knowledge which I provided to be included in my medical record.
This list includes any over the counter medications and herbal supplements, as well as regular and occasionally used prescription drugs.
Ear, Nose, Throat
Please indicate if you've had any of the following illnesses or medical conditions:
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