New Patient Registration Form

Cancellation and No Show Appointments Policy

Please note that it is important to fill in all the fields before submitting. Thank you.
Patient Name

First NameMiddle NameLast Name
We require a minimum of 2 business days notice for rescheduling or cancellation of an appointment. This will enable us to fill the time slot you have vacated with another patient in need of care.

Every effort will be made to contact you by phone/email to confirm and remind you of your appointment a day or two in advance. Please DO NOT rely on these calls to keep track of your appointments. A cancellation fee of $50 will apply for missed appointments.
Family member's name(s) ( Click on + to add more )
Thank you for being a valued patient and for your understanding and cooperation as we institute this policy. This policy will enable us to open otherwise unused appointments to better serve the needs of all patients.
I understand the above and agree to abide by this policy.
Patient /Parent Signature *

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Cancellation and No Show Appointments Policy