Notice to All New Patients

  • Cancellation, Reschedule, No-show of new patient appointments
  • By signing this form I acknowledge and understand that if I cancel a new patient appointment or request to reschedule with less than 48 hours notice, or if I am a no-show, I will be required to pay a fee of $150.00 in order to reschedule. If this rescheduled appointment is cancelled or I request to reschedule with less than 48 hours notice, or I am a no-show, I will not be allowed to reschedule again.
  • My signature below certifies that I have read the above information and had any questions answered to my satisfaction.
  • Hidden
    MM slash DD slash YYYY
  • MM slash DD slash YYYY