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We know how valuable your time is and we don't think our time is any more valuable than yours. When you schedule an appointment we reserve that time for you, so if you are unable to keep your scheduled appointment we need to know about it. If you cancel without giving 24 hours advance notice, the time is lost and cannot be reserved for another patient.
Due to past experience, we have found it necessary to enact the following policy to encourage our patients to be responsible in communicating with our office: 1. Appointment Cancellation Without 24 Hours Notice Any appointment canceled for any reason without 24 hours advance notice is subject to a charge at the rate of $25.00 per 1/2-hour appointment time. Any further appointments will then require advance payment. If you fail to show up for the rescheduled appointment, or fail to give 24 hours notice, the full payment will be kept by our office. However, if you are present for your rescheduled appointment, your account will be credited for the amount of the advance payment. Insurance may then result in a refund to you. 2. Not Showing Up or Late Arrival for Appointment If you fail to show up for an appointment, or if you are more than 15 minutes late, we will reschedule your appointment so we don't disrupt the service of other patients whom we have prior commitments with. You will be subject a charge at a rate of $25.00 per 1/2 hour of appointment time. This policy will have no effect on patients who are responsible for keeping their appointments or those who give the proper 24 hours advance notice. Thank you for being considerate.
I acknowledge that I have read and understand this policy.
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| Patient or Authorized Person's Signature | Date |