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 Xxxxxxx under the provisions, guidelines, and limits delineated above. Client Signature Date
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...
Missed Appointments. We require notice of cancellations 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 will apply. These fees are typically $50.
Examples of Missed Appointments in a sentence
Missed Appointments & Short Notice Cancellations Appointments will be on a weekly basis at a fixed time.
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. If you are unable to keep an appointment, please notify me by phone immediately. Please provide 24-hour prior notice if a cancellation is necessary. Should missed or appointments occur more than 4 times in a three month period without an emergency situation, I will require a credit card and charge 50% of the appointment fee for missed appointments per occurrence. This policy is meant as a standard of mutual respect between the client, Xxxxx Xxxxxx, LCPC, and the needs of other clients. Your consideration of advance notification makes it possible to give the appointment to someone else in need. Missed appointment fees are your responsibility, as insurance will not cover these costs. _ (Initial here) Appointment Reminders and Emails: Email and text appointment reminders are optional and will occur 48 hours in advance of your appointment in order to leave you enough time to cancel or reschedule. Your email address will never be shared or used for solicitation. Confidentiality: Confidentiality is the process in which any identifying information related to your case is not discussed outside of this office and is kept in a secure area to which only Xxxxx Xxxxxx will have access. Xxxxx Xxxxxx (hereafter known as the therapist) may consult with other professionals to enhance the services that you receive, although information provided will never be more than is required for the consultation. All mental health professionals are bound by ethical and legal obligations to maintain confidentiality. Signing this agreement constitutes release for consultation with professionals outside of this therapy office. You must sign a release of information before any identifying information about you is given to anyone outside this office. In matters of child or elder abuse or neglect, potential and/or imminent danger to self or others, or if the therapist is ordered by a court of law, the therapist has an ethical and legal obligation to inform appropriate agencies/persons and provide them with all necessary identifying information. Additionally, an exception may be made if there is outstanding debt for this therapy service. In the case of marriage and family therapy, therapists have unique confidentiality responsibilities because we have obligations to more than one person during this type of therapy. Information shared in individual sessions, phone conversations, or written messages may be shared with other family members who have consented to treatment with this office. Likewi...
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.
Missed Appointments. If you need to miss an appointment, please notify us 24 hours in advance or you will be assessed a $40 fee; If you miss your appointment, this is considered a No Show and will be assessed a $40 fee. If you miss an appointment that you scheduled on the same day, and it is not due to a visit to the emergency room or urgent care, then you will be assessed a $40 fee. In the event of 3 or more missed appointments or no shows occur, we may ask you to seek services from another practice and/or be assessed a $50 fee.
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. 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. 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