Center for Holistic Medicine Practice Policies Form

Office Policy:

We require a deposit to schedule the first initial visit. This deposit is non-refundable. To be considered an active patient an onsite visit must be made 1 time per calendar year. All follow ups must be done in person or by telephone (as recommended by your physician)

Cancellation Policy:

All services are provided by appointment only this scheduled time has been set aside for your one on one time with the physician. When you do not show up for a scheduled appointment, you are taking an appointment slot that could have been used for another patient. Cancellation policy differs by type of appointment as written below.

Functional medicine/Autism Spectrum consult: First Visit

All new patients are required to give a 1 week cancellation notice due to the length of the appointment and time spent by the physician reviewing your records. Center for Holistic Medicine retains the deposit of 200.00 as nonrefundable. If you do not call or just do not show up for your appointment you will be billed for the remaining amount of 200.00. (These appointments are very involved and the allotted time of 2 hours has been set aside for a one on one with the physician.)

Note: Appointments can be rescheduled at the physician’s discretion.

Functional Medicine/ Autism Spectrum Follow up appointment Cancellation:

We require 48 hours’ notice for follow up cancellations for Functional Medicine/Autism Spectrum management which includes office visits and telephone consults with the physician. (These appointments are 1 -2 hour appointments) Center for Holistic Medicine retains the right to bill 100.00 of the standard fee for any consultation not cancelled within 48 hours prior to the visit.

Acupuncture:

All New Patient Acupuncture appointments are secured with a nonrefundable deposit of 87.50. Patients are required to give a 1 week cancellation notice prior to your scheduled appointment. Center for Holistic Medicine retains the 87.50 deposit as nonrefundable if cancellation policy is broken.

Acupuncture Follow up appointments- We require a 48 hour notice for cancellation of follow up acupuncture visits. Center for Holistic Medicine retains the right to bill 75.00 of the standard fee for any consultation not cancelled within 48 hours of the scheduled visit.

Note: Any deposits made on an initial examination of any kind is non-refundable. We will hold these deposits to be applied toward your first exam for 6 months. Should you decide to cancel and not reschedule within that allotted time, the deposit will be applied as a cancellation fee and another deposit would be required for scheduling.

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.