BALZ05 Cancellation and No Show Policy

Cancellation & No-Show Policy

Para Español, seleccione del menú desplegable en la esquina superior derecha.

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

We understand that situations arise in which you may need to cancel or reschedule your appointment. To be respectful of the needs of all our patients, please be aware of the following policy:

Cancellations must be made at least 24 hours in advance of the scheduled appointment.
Appointments cancelled with less than 24 hours’ notice or missed without notice will be subject to a $50 fee.
This fee is not covered by insurance and must be paid in full before future appointments can be scheduled. Multiple late cancellations or no-shows may result in limited appointment availability or discontinuation of services.

We recognize that emergencies and unforeseen circumstances do occur. If this happens, we encourage you to contact our office as soon as possible to avoid the fee when appropriate.

By signing below, you acknowledge that you have read, understand, and agree to this cancellation and no show policy.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *