Policy Acknowledgement Form

Missed Appointment Policy

Office Policy Addressing Missed Appointments

• After the first missed appointment, a $25.00 fee will be charged. The appointment may be rescheduled.
• If a second scheduled appointment is missed, a $25.00 fee will be charged. Statement is sent, again reiterating our policy. The appointment may be rescheduled.
• If a third scheduled appointment is missed per family, it will be necessary to terminate our professional relationship with the patient and family. Termination letter is sent.

As a parent/guardian of a patient of Young Pediatrics I agree to pay any charges that may accumulate from missed appointments.

I have received a packet of Young Pediatrics Appointment, After Hour/Exchange, Health Forms, Disclosure of Health Records, and Office Financial Policies.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.