When an appointment is made for you or your child in our office we reserve doctor and staff time, reserve workspace, and get instruments and materials ready specifically to provide your treatment at that time. When patients, for any reason, break appointments by not coming or being late, all or a portion of these resources are wasted. This is always costly for the office and in the case of being late it often inconveniences subsequent patients by making us late to see them.

The following are considered broken appointments:

• Missed appointment : Not coming for your appointment is considered a broken appointment.
• Cancelled appointment : Any appointment that you call to cancel or change less than 24 hours in advance is considered a broken appointment.
• Late for appointment : Many orthodontic appointments are only 15 to 30 minutes long. If you arrive late for your appointment and we are unable to see you due to the amount of time your appointment requires, it is considered a broken appointment.

All broken appointments will result in a broken appointment charge of $50. This will be automatically charged to your account. Broken appointment charges are not billable to, nor payable by insurance providers.

My signature below verifies that I understand and agree to the office policy for broken appointments including missed, late for, late cancellation of, and late change of appointments. I agree I am responsible for broken appointment charges applied to my account as a result of the actions described above.