No-Show Policy Acknowledgment Form

No-Show & Cancellation Policy Cancellation Policy We understand that circumstances may arise that require you to cancel or reschedule an appointment. We respectfully request that you provide at least 24 to 48 hours' notice if you need to cancel or reschedule. This advance notice allows us to offer the appointment time to another patient who may be waiting for care. Cancellations made with less than 24 hours' notice may be subject to a cancellation fee. - First occurrence: A courtesy reminder of this policy will be issued. - Subsequent occurrences: A cancellation fee of up to $50 may be charged to your account. - Repeated late cancellations may result in the requirement of a deposit for future appointments.

No-Show Policy A no-show is defined as a missed appointment without any prior notification. No-show fees help us maintain an efficient schedule and ensure timely access to care for all patients. - No-show fee: A fee of up to $75 may be charged for missed appointments. - Three or more no-shows within a 12-month period may result in dismissal from the practice. - No-show fees are not billable to insurance and are the patient's sole responsibility. We value your time and ask that you value ours. If you are running late, please call our office as soon as possible so we can accommodate you or reschedule.

I have read and understand the cancellation policy, including the requirement to provide at least 24 to 48 hours' notice for cancellations.

I have read and understand the no-show fee policy and accept that fees may be charged for missed appointments without prior notice.