We will make every effort to accommodate your scheduling needs. In return we ask that you help us by keeping your scheduled appointments and by notifying us at least 24 hours in advance when possible if you are unable to do so. When you give us advance notice we are able to accommodate other patients.
First missed appointment – Parents will receive a phone call informing them of their child’s missed appointment
Second missed appointment – Parents will receive a letter informing them that they have now missed two appointments and they will be charged a $40.00 fee. Insurance will not pay for this charge. Insurance will not cover this.
Third missed appointment - Parents will be charged an $80.00 missed appointment fee. Further missed appointments may result in dismissal from our practice.
Parents bringing in two or more children at the same time will be restricted from scheduling a double or triple well appointment after missing two such appointments for multiple children.
Thank you for your courtesy.
Disclaimer: 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.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use: