Our Appointment Cancellation Policy allows us to schedule appointments for all patients. When an appointment is
scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another
patient. Our policy is as follows: We require that you give our office 24 hour notice in the event that you need to
reschedule your appointment. This allows for other patients to be scheduled into that appointment. If you miss an
appointment without contacting our office within the required time, this is considered a NO SHOW. A fee of $35.00
will be charged to you, this fee cannot be billed to your insurance company and will be your direct responsibility.
No future appointments can be scheduled nor can records be transferred without the payment of this fee.
Additionally, if a patient is more than 20 minutes late without prior notice for a scheduled appointment, we will
consider this a NO SHOW and the $35.00 cancellation fee will be charged to you. If you miss three appointments
without giving us 24 hour notice, we will not be able to reschedule your appointment and you will be dismissed as a
patient. If you have any questions regarding this policy, please let us know and we will be glad to clarify any
questions you have.
I have read and understand the above policies.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
