No-show, Missed appointment office policy form
When our office books your appointment, we are setting aside a dedicated time slot just for you. We only ask that if you must reschedule your appointment, that you please provide us with at least 24 hours notice. This courtesy makes it possible to give your reserved time slot to another patient who would be more than happy to accept. There is a charge of __(FILL IN $)__ per hour for not showing up for scheduled appointments. *Repeated cancellations or missed appointments will result in loss of future appointment privileges. Every patient in our practice receives this unique reservation. When your appointment is made, a time is reserved, your materials are ordered and we make special arrangements to be ready for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you. Credit card appointment reservation form Please take notice. The card that is provided below will only be charged on the day of your scheduled appointment if your appointment is not cancelled within the requested 24-hour notice policy. Credit Card no. Card type Expiry date CC Security Code (3 digits) Amex Sec Code (4 digits) Patient name Patient signature Date