Cancellation / No Show Agreement For Doctor Appointment And Surgery

Please correct the errors described below.

1. Cancellation/No Show Policy for Doctor Appointments

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much-needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment schedule. Canceled appointments/no shows are a major financial burden for this and every medical practice and cannot be tolerated. If an appointment is not canceled at least 2 business days in advance, you will be charged a fifty dollar ($50) fee; this will not be covered by your insurance company. Chronic cancellations/no shows will result in the patient being discharged from the practice.

2. Scheduled Appointments

We understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient is 15 minutes, or more, past their scheduled time, we reserve the right to reschedule the appointment to another day or move the appointment to a later time slot on the same day if the doctor’s schedule allows.

3. Cancellation/No Show Policy for 2hr Appointments (Crowns, Bridges, Root Canals, Surgical Procedures, Etc.)

Due to the large block of time needed for specific procedures, last minute cancellations can cause problems and added expenses for the office. If a patient does not cancel with at least 2 FULL BUSINESS DAYS (not including weekends) in advance you will be charged a seventy five dollar ($75) fee, this fee will not be covered by your insurance company.

4. Account Balances

We will require that the patient with a self-pay balance bring their account balance to zero (0) prior to receiving further services by our practice. Patients who have questions about their bills, or who would like to discuss a payment plan option, may call and ask to speak with a business office representative with whom they can review their account.

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