48 hours notice
is also required for
cancellations of appointments.
A $40 fee
will be charged for a missed appointment, if no prior notice is given to our office. Should you fail to attend your initial appointment with us without notice you will be billed up to
of the initial visit fee.
By notifying us of your change in schedule, you allow someone else to receive the vital treatment they need.
Please take a few minutes to answer the questions in ink on the following pages. All of your medical information is of value to us. If your condition is not well covered by the questions that follow, please feel free to write it in.
Please read the enclosed fee schedule.
I have read the fee schedule and asked questions to clarify anything that was not clear to me. I completely understand what I am signing and agree to abide by the clinic rules as outlined above.