Missed Appointments. Policy Agreement Missed appointments represent a loss of an opportunity for someone else to receive services from me. Therefore, I would appreciate knowing as soon as possible if you are going to miss an appointment. Without a full 24 hours notice, I will have to charge you the full fee for any session that is missed. Please note, any late arrival of equal to or greater than 20min from the start of the scheduled appointment time will be considered a “missed visit” and will be charged to you the full fee as well. If you are running late for your appointment, please notify our central intake office as soon as possible (1-855-593- 1157). I have read both pages of this agreement and fully understand each section of this form and agree to participate in counseling services with Xxxxx Xxxxxxxx under the provisions, guidelines, and limits delineated above. Client Signature Date
Missed Appointments. We require notice of cancellations at least 24 hours in advance. This allows us to offer the appointment to another patient. If you fail to keep your appointments without notifying us in advance, a missed appointment fee of $50 will apply. Procedures not covered by insurance remain the responsibility of the patient.
Missed Appointments. Missed appointments are monitored because of the critical lack of access to medical services in our area. Patients who miss an appointment will receive notification advising them that they have missed an appointment which could impact their health and wellness. Patients who miss 3 appointments will receive a warning notification of 3 or more missed appointments and possible wait time to be seen by provider, with no appointments scheduled after 2:00 PM. Please contact the health center if you have any questions about our Appointments Policy. : By initialing I understand and agree to abide by this Appointments Contract. Patient Signature: Date: (must be signed and dated each year) DENTAL HEALTH HISTORY Primary Care Physician: Phone: Medical Specialists: _ Phone: _ Have you had any major health problems in the past 5 years? (serious illness, hospitalization, surgery) Do you have a dental emergency or major dental problem? How long has it been since your last dental appt? Are you required to take an antibiotic before any dental treatment? [ ] YES [ ] NO If yes, why? _ Do you have any of the following: (please circle) sensitivity hot/cold clicking/popping of jaw reconstructive surgery burning tongue bleeding/sore gums food impaction now biting sensitivity periodontal surgery swelling grinding/clenching headaches orthodontics pain in teeth now Allergies: Are you allergic to or have you had a reaction to: (please circle) penicillin latex ibuprofen any metals sulfa drugs local anesthetic sedatives food other antibiotics fluoride aspirin codeine acetaminophen Medications: Are you currently taking any medications, over the counter drugs, or natural/herbal supplements? [ ] YES [ ] NO Do you take any blood thinners? (Plavix, Coumadin, Warfarin, or Aspirin)? [ ]YES [ ]NO medication/supplement strength/dosage # of times a day reason Important health information: Do you use, have or had, any of the following? (please circle) artificial joints/limbs cancer rapid weight loss kidney disorder/dialysis heart stents chemotherapy radiation therapy neurologic disorder artificial heart valves asthma/inhalers cleft palate/lip narcotic use pace maker TB alcohol use marijuana use heart attack arthritis cold sores drink cola/pop stroke systemic lupus hemophilia tobacco use high/low blood pressure rheumatic fever AIDS/HIV Type How much per day? heart murmur anxiety attacks hepatitis A/B/C mitral valve prolapse eating disorder diabetes type 1/2 Women only: (please circle) Are you pregn...
Examples of Missed Appointments in a sentence
Missed appointments without 24 hours notification or a reasonable explanation will be chargeable in full as per the fees set out on the xxxxxxxxxxx.xxx website.
More Definitions of Missed Appointments
Missed Appointments. An appointment is a reservation of our office and staff for your imaging needs. This time is taken from someone else if we do not have adequate notice of cancellations. Please give us at least 24 hours’ notice if you cannot keep your appointment.
Missed Appointments. Unless canceled at least 24 hours in advance, our policy is to charge $25 for missed appointments. We will not file, nor will insurance plans pay for this charge, so please help us serve you better by keeping, or cancelling in advance, scheduled appointments. COLLECTIONS: Failure to pay account balance within 30 days from initial billing may result in interest charges up to maximum legal amount allowed by law and handling fee of $10. Any past due balance not paid will be turned over to a collection agency after 90 days. Any charges and fees resulting from this action, including collecting agency fees, will be added to your account balances and will be your responsibility. In the event that the bill remains unpaid and litigation ensues for collection of sums due, this office shall be entitled to reasonable attorney fees and court costs.
Missed Appointments. Policy Agreement Missed appointments represent a loss of an opportunity for someone else to receive services from me. Therefore, I would appreciate knowing as soon as possible if you are going to miss an appointment. Without a full 24 hours notice, I will have to charge you the full fee for any session that is missed. Please note, any late arrival of equal to or greater than 20min from the start of the scheduled appointment time will be considered a “missed visit” and will be charged to you the full fee as well. If you are running late for your appointment, please notify our central intake office as soon as possible (0-000-000-0000). I have read and agreed to the above. Client Signature Date
Missed Appointments. Our policy is to charge for missed appointments unless a cancellation is received at least 24 hours in advance. The charge is $50 per hour of scheduled time. I acknowledge that I am responsible to pay all charges for treatment administered by 4th Avenue Family Dentistry as outlines above and that if my account is placed with a collection agency for non-payment that I will be responsible for all collection costs, including court costs and associated attorney fees. I have read the policies and agree with the terms outlined above. Responsible Party Signature: Printed Name: Date:
Missed Appointments. When you schedule an appointment, that time is exclusively reserved for you. We request you give us at least 24 hour notice if you need to reschedule an appointment. When the requested time is not given, a fee of $25 per half hour will be charged to your account per client. Payment is due at time of services: We accept cash, checks and most major credit cards for your convenience. When insurance applies, we will collect any deductibles and co-payment at the time of service. We also offer payment options with Care Credit and The Lending Club for more extensive treatment plans.
Missed Appointments. Our policy states that after 2 missed appointments, we require a credit card hold of $150. On the 3rd no show/same day cancellation appointment, we will charge you $150. Please help us serve you better by keeping your scheduled appointment.
Missed Appointments. If you miss or cancel your appointment with less than a 24hr notice, our office reserves the right to bill you $50.00 for each no show or late cancelation. The fee will be your responsibility and will not be billed to your insurance.