Cancellation Policy

Please be advised effective immediately that if you cancel or no-show for an appointment more than 3 times, we will be forced to discharge you from this practice. No-Show and late cancellations waste precious time that other patients could use. We are committed to meeting our patients’ health care needs.

Thank you,

Management

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

No Show Policy

We are committed to meeting our patients’ health care needs. No-show and late cancellations waste precious time that other patients could use.

Please be advised of our office policy.

All appointments must be cancelled by noon of the previous day (or by 10:00 AM Friday for a Monday appointment) to avoid charges for a no-Show or late cancellation. PLEASE NOTEL Insurance does not cover charges for no-show/ late cancellation fee: therefore, the patient is responsible for payment.

~LATE CANCEL fee of $40.00 will be charged to the patient~

~NO SHOW fee of $50.00 will be charged to the patient~

~A NO SHOW/LATE CANCEL fee of $75.00 will be charged to the patient for any scheduled procedure~

Billing Questions:

If you have any questions regarding billing, please call our office during regular office hours.

I have received a copy of this document and understand that I will be financially responsible for the following:

All missed scheduled appointments that are not cancelled as described in the policy above.

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

Thank you for your continued support of our practice

If you believe we have made an error in scheduling or you believe you deserve special consideration, please call or provide an appeal in writing for consideration.