We are committed to providing you with the most ethical and effective treatment, we value every appointment that we schedule and will reserve that d ay and time for you. This reservation, however, also preserves your clinician’s time and precludes Dr. Gomez from scheduling other clients. Therefore, if you are unable to attend your session, we require that you call our office and Cancel the appointment with a minimum of 24 hours.
Self-pay patients that do not attend their scheduled appointment or do not cancel within 24 hours will be charged the full amount of the appointment. Patients with insurance will be charged the full amount of their co pay and a missed appointment fee of 90$ Dollars.
By filling out this form I understand that Mencia Gomez, MD will charge my credit card ONLY in the event that I do not attend my scheduled session OR I do not cancel with a minimum of 24-hour wor king days (Mon-fridays) notice. Otherwise my card will not be charged