New Patient Appointment Booking Form

Orofacial Pain Associates of Colorado Springs

719-260-0600

This form is used only to collect the basic information needed for scheduling, communication, and administrative purposes.
Additional medical history and intake forms will be completed separately prior to your visit.

Patient Information

First Name

Last Name

Birthdate

Gender

Mobile Phone #

Home Phone #

Email Address

Street Address

City

State

Preferred Contact

Home Phone Mobile Phone

Would you like to receive appointment reminders?

Yes No

Do you want an invite to the patient portal? If yes, an email is required.

Yes No

Certification and Appointment Policy Acknowledgment

I certify that the information provided above is accurate and complete to the best of my knowledge.

I acknowledge that this form is used to finalize and confirm my appointment with Orofacial Pain Associates.

I understand that if I need to cancel or reschedule my appointment, I must provide 48 hours notice in accordance with the office cancellation policy. Appointments cancelled on the same day as the scheduled appointment may be subject to the full cost of the appointment.

I understand that failure to provide timely notice may result in a cancellation fee or financial responsibility for the full appointment charge.

I authorize Orofacial Pain Associates to contact me regarding appointment scheduling, reminders, administrative matters, and billing communications using the contact information provided above.

Orofacial Pain Associates New Patient Appointment Deposit Policy

Our practice has implemented this policy to ensure that appointment times remain available for patients in need of care. Missed appointments and late cancellations result in lost time that cannot be offered to other patients.

A $100 deposit is required at the time of scheduling to secure all new patient appointments.
This deposit is non-refundable, except as outlined below, and is required to reserve your appointment time.

Cancellation / Rescheduling Policy:

We require at least 48 hours’ notice to cancel or reschedule an appointment.
48 hours or more notice: The appointment may be rescheduled, and the $100 deposit will be applied to the rescheduled appointment.

Less than 48 hours’ notice or failure to attend (no-show):The $100 deposit is forfeited in full and will not be applied or refunded.

If a patient cancels or reschedules with less than 48 hours’ notice or does not attend their appointment, a new $100 deposit will be required to schedule any future appointment.

By scheduling an appointment and submitting your deposit, you acknowledge that you have read, understood, and agree to this policy.

I understand that a $100 deposit is required to schedule my appointment, is non-refundable, and will only be applied to my appointment if I provide at least 48 hours’ notice to reschedule.

I understand that my $100 deposit must be received within 24 hours of scheduling. Failure to submit my deposit within 24 hours may result in the loss of my appointment time.

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