NO-SHOW / LATE CANCELLATION POLICY

Broken appointments represent a cost to us, to you, and to the other patients who could have been seen in the time set aside for you. If you have an unexpected event, please call to inform us that you need to reschedule within 24 hours of your appointment time. Patients who do not show for an appointment without calling will be charged a $75.00 no-show fee. $100 for procedures. You will not be able to reschedule until the no-show fee is paid in full. Missing two appointments is grounds for discharge from the practice. Patients who arrive late, missing more than half of their appointment slot, will be offered appointments at the end of the schedule, if possible, or rescheduled. Please ensure that we have updated contact information to remind you of any upcoming appointments. By completing this form you are acknowledging and agreeing to our No-Show / Late Cancellation Policy. Thank you for being a valued patient and for your understanding and cooperation in regards to this policy.

Payment Information

Credit Card number is required Expiration Month is required Expiration Year is required CVV2 is required Check Name is required Routing Number is required Check Account is required Account Holder Type is required

Billing Information

First Name is required Last Name is required Company is required Phone is required Fax is required Email is required Website is required Address 1 is required Address 2 is required City is required State is required Zip is required Country is required

First Name:
Last Name:
Address 1:
City:
State:	Alberta Alaska Alabama Arkansas Arizona British Columbia California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Manitoba Maryland Maine Michigan Minnesota Missouri Mississippi Montana New Brunswick North Carolina North Dakota Nebraska New Foundland New Hampshire New Jersey New Mexico Nova Scotia Northwest Territories Nunavut Nevada New York Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island South Carolina South Dakota Saskatchewan Tennessee Texas Utah Virginia US Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Yukon
Zip:
Email:

Patient Information

Account Number: is required First Name: is required Last Name: is required Date of Birth (MM/DD/YY): is required Custom Field 5 is required Cardholder Consent is required Custom Field 7 is required Custom Field 8 is required Custom Field 9 is required Custom Field 10 is required

Account Number:
First Name:
Last Name:
Date of Birth (MM/DD/YY):
Cardholder Consent	I accept the No-Show / Late Cancellation Policy