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. Gregory Lesser, Guida St. George, PA-C, 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.

​

Privacy Policy

Privacy Policy (with SMS / Texting Addendum)

1. Introduction

NJ Gastro (“we,” “us,” “our”) respects your privacy. This Privacy Policy explains how we collect, use, share, and protect your personal information, including phone numbers used for SMS / texting, in compliance with RingCentral’s SMS/MMS and TCR requirements, and applicable laws (such as U.S. state consumer privacy laws, TCPA, etc.).

By using our website and/or consenting to receive SMS from us, you agree to the collection and use of your personal information as described herein.

2. What Information We Collect

We may collect the following types of personal information:

• Contact information: name, email address, postal address, phone number (including mobile).

• SMS consent data: timestamp of opt-in, IP address (if opted in via web form), campaign name or keyword, log of opt-out requests.

• Usage data: metadata about how you interact with our website (pages visited, links clicked), device and browser info, IP address, cookies or similar tracking technologies.

• Communications data: records of your communications with us (e.g. email, SMS replies).

• Other information: any other information you voluntarily provide (e.g., in feedback forms, surveys).

We collect this information directly (e.g. when you fill out a form, sign up for SMS, contact us) and automatically (via cookies, analytics, logs).

3. How We Use Your Information

We use personal information for the following purposes:

• To send SMS / text messages you have opted in to receive (e.g. appointment reminders, notifications, promotional offers)

• To respond to your inquiries and provide customer support

• To maintain and improve our website, services, and functionality

• To monitor usage, analyze trends, detect fraud, security, and ensure compliance

• To send marketing materials, newsletters, offers (if you have opted in)

• To comply with legal obligations or enforce our terms

We will not use or disclose your SMS opt-in / consent data in a way that would violate RingCentral’s requirements or your reasonable expectations of privacy (see Section 5).

4. SMS / Text Messaging Terms & Disclosures:

4.1 Consent & Opt-in

• We will only send SMS messages to you if you have given express written consent (e.g. via a web form checkbox, text keyword, or other opt-in mechanism) prior to sending promotional or informational messages.

• For promotional or marketing messages, you must explicitly opt in (implied consent is not sufficient). (See RingCentral policy: “Marketing or promotional messages require the recipients’ express prior written consent.”) (RingCentral)

• We record and log the date/time, IP address (if web), and the form or campaign via which you opted in.

• You may be asked to confirm your phone number (e.g. via SMS double opt-in) as an extra verification step.

4.2 Types & Frequency of Messages

• We may send you messages such as appointment reminders, status updates, transactional notices, alerts, and promotional offers (if opted in).

• Message frequency may vary.

• Message & data rates may apply depending on your mobile carrier (standard carrier charges).

• We will not send more messages than necessary, and will strive to avoid excessive frequency.

4.3 Opt-out / Unsubscribe

• Every SMS or text message you receive from us will include clear opt-out instructions (for example: “Reply STOP to opt-out,” or “Reply STOP to unsubscribe”).

• We will honor opt-out requests promptly and cease sending further messages (except possibly a confirmation that you have been unsubscribed).

• You can also get help by replying “HELP” or by contacting us at [support email / phone].

• We will maintain and enforce a suppression list internally to prevent sending messages to those who have opted out.

4.4 Sharing & Use of Phone / SMS Consent Data

• We do not share, sell, rent, or otherwise disclose your mobile number or SMS opt-in/consent data to third parties, affiliates, or marketers, except as needed for delivering the service (e.g. SMS providers, RingCentral, or compliance).

• Where we engage third-party service providers, we require them to use your data only for the purposes we specify and to adhere to confidentiality and security obligations.

4.5 Restrictions & Prohibited Content

• We will not send messages that violate RingCentral’s prohibited campaign or content guidelines (e.g. no credit repair, debt relief, gambling, affiliate marketing, secret shopper, illegal content, etc.). (RingCentral)

• We will not use link shorteners or obscure links in SMS messages (to avoid spam filters) and we will use branded or recognizable domains. (RingCentral)

• We will not use purchased lists, third-party lead lists, or share phone numbers between campaigns that were not collected via our own consent process. (RingCentral)

4.6 Registration & Compliance

• We will register our SMS use cases and campaign types with The Campaign Registry (TCR) as required under U.S. A2P 10DLC rules. (RingCentral Community)

• We maintain a working website with a publicly available version of this Privacy Policy and a link from our forms. RingCentral requires the Privacy Policy link to be present and clearly accessible for TCR registration. (RingCentral Support)

• During application for SMS registration, we will supply sample messages with our business name, opt-out language, and typical content. (RingCentral Support)

5. Disclosure to Third Parties & Data Sharing

We may share your personal information under limited circumstances:

• With service providers or processors (e.g. mailing platform, SMS gateway, analytics provider) strictly under contract to perform services on our behalf and under confidentiality obligations.

• With legal or regulatory authorities when required by law, court order, or to protect rights, safety, or property.

• In connection with corporate transactions (e.g., merger, acquisition, restructuring), provided that the acquirer agrees to be bound by this Privacy Policy or a materially similar one.

Your SMS opt-in data and phone number will never be sold, rented or otherwise disclosed for marketing by third parties.

6. Retention of Data

We retain your personal information only as long as necessary to fulfill the purposes in this policy (e.g. maintain SMS communication, legal compliance, dispute resolution). After that, we securely delete or anonymize it.
Specifically, we keep opt-in/opt-out logs and phone numbers for a reasonable period in compliance with applicable recordkeeping requirements and RingCentral requirements.

7. Security

We take reasonable administrative, technical, and physical measures to protect your personal information from unauthorized access, disclosure, alteration, or destruction.
While no security system is perfect, we strive to safeguard your data. In the event of a data breach, we will notify affected parties and authorities when required by law.

8. Your Rights & Choices

Depending on applicable law, you may have the right to:

• Access, correct, update, or delete your personal information

• Withdraw consent or opt-out of receiving marketing SMS/text communications

• Object to or restrict certain processing

• Lodge a complaint with a data protection authority

To exercise your rights, please contact us at:

NJ Gastro

24 Merchant Street, Newark, NJ 07105

Njgastrollc.app@gmail.com

973-645-0000
 

9. Children

We do not knowingly collect or solicit personal information from children under the age of 13 (or higher if local law sets a higher age). If you become aware that a child has provided us with personal data, please contact us, and we will delete that data from our records.

10. Changes to This Policy

We may update this Privacy Policy from time to time to reflect changes in our practices or legal requirements. We will post the updated version at this URL and update the “Last updated” date. Significant changes may be communicated by email or website notice.

11. Contact Us

If you have questions or concerns about this Privacy Policy or our practices, please contact us at:

NJ Gastro

24 Merchant Street, Newark, NJ 07105

Njgastrollc.app@gmail.com

973-645-0000