Cancellation Policy

ATTENTION: There will be a $40 cancellation fee applied to any patient who cancels their appointment without giving the office at least 24 hours notice.

I have been notified of the $40 cancellation fee that will be applied to me if I do not notify the office at least 24 hours before canceling my appointment. Payment method for cancellation fee: All credit cards accepted.

Patient's Name:
Patient's Signature:_____________________________ Date:_____________
Witness:_________________________

NOTE: You will have an opportunity to sign this form during your next visit.