No Show Policy Form

To all of our patients,
Effective January 1, 2019

When our office books your appointment, we are setting aside a dedicated chair and 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 $50 per hour for not showing up for scheduled appointments.

There is a charge of $75 per hour for not showing up for scheduled late night or Saturday 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.

I have read and understand the above policies.


Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.