Appointment Cancellation Policy / No Show Policy

(Telehealth or Brick-and-Mortar)

Date: {{current_date}}

Patient Information

**Patient Name: {{patient_first_name}} {{patient_last_name}} {{patient_first_name}} {{patient_last_name}}** {{patient_input}}
**Birthdate:** {{patient_input}}

Policy Details

1. Cancellation Policy / No Show Policy

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you are preventing another person from getting treatment.

If an appointment is not canceled at least 24 hours in advance, you will be charged a twenty-five dollar ($25) fee.

2. Scheduled Appointments

We understand that delays can happen due to a variety of issues, however we must try to keep other patients on time. If a patient is 15 minutes past their scheduled appointment, we may have to reschedule the appointment.

3. No-Call Cancel / No Show Policy

No-Call Cancel / No Show for more than two "2" appointments may result in dismissal from program with no refund.

Consent and Agreement

I acknowledge that I have read, understand, and agree to abide by the Cancellation / No Show Policy.

I consent to the terms of this Cancellation and No Show Policy

I understand that I may be charged a $25 fee for late cancellations

Signatures

Member Signature: _________________________ Date:

Witness Signature: Date:

Form Complete

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Membership Cancellation Policy