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 has 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.

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Privacy Policy

We respect the privacy of visitors to the NJ Gastro, LLC website at njgastroenterology.com and the Ironbound Endo Surgical Center website at ironboundcenter.com (collectively, the “Sites”).This Privacy Statement explains how NJ Gastro, LLC (“NJ Gastro” or “we”) collects, uses, shares, stores, and protects the information that we collect from you when you visit our Sites, as well as your rights and choices regarding the information that we collect. This Privacy Statement does not apply to information collected from other sources, whether offline or online. This Privacy Statement also does not apply to any third-party websites to which the Sites may link or from which the Sites may be linked. NJ Gastro does not control the content or privacy practices of third-party websites.

The Sites are intended for U.S. residents only. Please read carefully the Terms of Use for information on the purpose and use of the Sites.

Privacy of Personal Information

For purposes of this Privacy Statement, “personal information” means any information that may be used to identify an individual. Personal information includes information such as your name, address, telephone number, e-mail address, and other similar information.

COLLECTION OF PERSONAL INFORMATION

To access updated features of the Sites, you must first complete a brief registration form. During registration you are required to provide certain personal information (such as name and email). By registering, you agree to receive certain communications from NJ Gastro. After registration, you may be given the option as to whether or not you want to receive other types of communication from us.

We collect personal information about you, including personal information that you provide when you register to use the Sites (as described above). You may access and browse portions of the Sites without disclosing personal information. Please be aware, however, that providing certain requested information may be necessary for you to participate in particular features or services described on the Sites.

USE OF PERSONAL INFORMATION

Personal information collected through our Sites is used by us to, among other things, process and manage registrations, operate and improve our Sites, track the Sites’ usage policies and statistics, make the Sites or services offered through the Sites easier to use by eliminating the need for you to repeatedly enter the same information, and for other purposes pursuant to your consent. We also use your personal information to communicate with you in other ways. For instance, when you register on this site, we may use your personal information to send you an email confirming your registration. We also use personal information to inform you of significant changes to this Privacy Statement.

DISCLOSURE OF PERSONAL INFORMATION

We may provide personal information to other companies who provide services on our behalf, such as creating your account, handling the processing and delivery of communications, hosting the Sites, and delivery of content and services provided by the Sites.

We may access, use or disclose your personal information for other reasons, including if we believe such action is necessary to comply with the law or legal process, protect and defend our rights or property, protect the personal safety of users of our website or members of the general public, enforce our Terms of Use or other agreements, investigate or take action with respect to illegal or suspected illegal activities, in connection with a corporate transaction, such as a divestiture, merger, consolidation, asset sale, or in the unlikely event of bankruptcy, or otherwise pursuant to your consent.

Personal information will not be posted or published by us, and except as specified in this Privacy Statement, it will not be provided to third parties.

ACCESS TO PERSONAL INFORMATION

To update or change the personal information you have provided NJ Gastro, or to unsubscribe from NJ Gastro, email njgastrollc.app@gmail.com.

Security

We have implemented procedures to help protect the personal information that you provide to us. However, no method of transmitting or storing electronic data is ever completely secure, and we cannot guarantee that such information will never be accessed, used, or released in a manner that is inconsistent with this Privacy Statement.

Children’s Privacy

We do not knowingly collect personal information from children under 13. Should we learn that a child under 13 has provided us with personal information we will delete that information from our database.

Our Practices with Respect to Non-Personal Information

We may collect other, non-personal information about your visit, including the pages you view, the links you click, and other actions taken in connection with your use of the Sites. We may also collect certain standard information that your browser sends to every website you visit, such as your Internet address, browser type and language, access times, and referring website address. We may use “cookies” (a small, unique identifier text file) and web beacons to gather non-personal information, including information about your experience with the Sites (e.g., if you arrived at the Sites via a link from third-party website, our cookie files may include the URL of the linking page). We view non-personal information as non-confidential, and we may use or disclose non-personal information without restriction or obligation to you. However, we may combine non-personal information with other information, including personal information we have collected about you. If we do combine non-personal information with personal information in this way, we treat the aggregate information in accordance with the practices for personal information that are described in this Privacy Statement.

Changes to This Privacy Statement

We may update this Privacy Statement in the future. We will notify you about material changes to this Privacy Statement by sending a notice to the e-mail address you provided to us or by placing a prominent notice on the Sites.

Contact Us

If you have any questions or suggestions regarding our Privacy Statement, please contact us at following address: njgastrollc.app@gmail.com.