We strive to render excellent dental care to you and the rest of our patients. In an attempt to be consistent with this, we have an Appointment Cancellation Policy that allows us to schedule appointments for all patients. When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patient who might be in pain and require urgent care. We value your time so we endeavor to run on schedule. However, late arrivals notonly affect us but the rest of our patients,therefore,late arrivals may result in rescheduled appointments.
Please understand that it is your responsibility to keep track of your appointment. As a courtesy, we contact you prior to your appointment to remind you, but it is ultimately your responsibility to ensure that you will be at your appointment on time.
Our policy is as follows:
Due to continuous high demand in prime appointment times, we require that you give our office 48 business hours notice in the event that you need to reschedule your appointment. This allows for other patients to be scheduled into that appointment. If you miss an appointment without contacting our office by telephone within the required time, this is considered a missed appointment. A fee starting at $50.00(assessed based on the length of your appointment)will be charged to you; (If a family is booked, that is $50 per person) this fee cannot be billed to your insurance company and will be your direct responsibility. No future appointments can be scheduled nor can records be transferred without the payment of this fee.
In the event that you do not show up for your scheduled appointment twice, we will be happy to assist you in transferring your records to the office of your choice with a letter explaining why the transfer has been made.
Additionally, if you are more than 20 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $50.00 cancellation fee will be charged.
If you have any questions regarding this policy, please let our staff know and we will be glad to clarify any questions you have.
We thank you for your understanding.
I have read and understand the Appointment Cancellation Policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.
I, (print name), have received a copy of Aqua Dental Appointment Cancellation Policy.
Signature of Patient: