Samuel N. Marcus M.D., Ph.D.

EL CAMINO GI MEDICAL ASSOCIATES

CROHN'S & COLITIS MEDICAL CLINIC

Patient Registration Form

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  • (Please indicate which contact number/email confidential communications may be relayed.)
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  • Name of friend or relative that we may contact in case of emergency:
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  • I, the undersigned, understand the payment policies of this office and understand that I am financially responsible to the treating physician for all charges incurred regardless of insurance coverage. If the amount due is not paid, I agree to bear collection costs, court costs, and legal fees.
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