No-Show/Cancellation Policy

No-Show/Cancellation Policy

  • The office requires a minimum of 24-hour notice for cancellation of any scheduled office visit. This courtesy will allow our office to schedule other patients waiting for appointments.

    If you fail to cancel your appointment more than 24 hours in advance, or if you do not show up for your appointment, your account will be charged the amounts below. You will be personally responsible for the amount you are charged since insurance does not pay for no-show appointments.

    • In-Office Procedures $100.00
    • In-Hospital Procedures $100.00
    • Medical Appointments $50.00

    This fee will need to be paid prior to any future appointments. Failure to pay this fee in a timely manner will result in your account going to collections.

    I acknowledge this office requires a minimum of 24 hours’ notice for cancellation of appointments.
  • Please input your full name as a signature on this form.

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