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No-Show Policy Acknowledgment Form
Registration

No-Show Policy Acknowledgment Form

1 page•8 fields•HIPAA-ready
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No-Show Policy Acknowledgment Form
Patient Full Name
Date of Birth
Phone Number
Email Address
I have read the no-show policy
I understand cancellation fees may apply
Preferred Appointment Reminder Method
Select...
Patient Signature
Sign here
Submit
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The No-Show Policy Acknowledgment Form clearly communicates your practice's expectations regarding appointment attendance, cancellation windows, and any associated fees. By having patients review and sign this form during registration, you establish a mutual understanding that helps reduce missed appointments and last-minute cancellations that disrupt your schedule.

This form outlines specific policy details including the required cancellation notice period, fees for no-shows or late cancellations, and the consequences of repeated missed appointments. It also includes provisions for emergency exceptions and the process for rescheduling. The clear, patient-friendly language ensures comprehension while protecting your practice legally.

Perfect for any medical or dental practice that experiences frequent no-shows. Behavioral health practices, physical therapy clinics, and specialty offices with long wait lists benefit especially from this form, as missed appointments directly impact patient access and practice revenue.

What's included

  • Clear policy statement with cancellation timeframes
  • Fee schedule for no-shows and late cancellations
  • Emergency exception provisions
  • Preferred reminder method selection
  • Acknowledgment checkboxes for each policy point
  • Legally binding patient signature

Who uses this template

  • New patient registration packets
  • Behavioral health and therapy practices with high no-show rates
  • Specialty clinics with limited appointment availability
  • Physical therapy and rehabilitation centers

All form fields

8 fields across 1 page. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Phone NumberPhone
Email AddressEmail
I have read the no-show policyCheckbox
I understand cancellation fees may applyCheckbox
Preferred Appointment Reminder MethodDropdown
Patient SignatureE-Signature

Use this template

Sign up and start customizing the No-Show Policy Acknowledgment Form for your practice. 30-day money-back guarantee.

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$79.99/mo · Cancel anytime · HIPAA compliant

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