Office Policies
I understand and agree to the conditions of this policy.
_______________________________________________ _________
Signature of Patient or Legal Guardian if patient is a minor Date
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Printed Name of Patient or Legal Guardian if patient is a minor
- I understand that all health services rendered to me and charged to me are my personal financial responsibility.
- All payments are due at time of check-in.
- I acknowledge that I should arrive at minimum 10 minutes prior to my appointment time to check in and be ready for the start of my appointment time.
- Notice of a cancellation or reschedule must be received at least 24 hours prior to appointment time.
- Failure to give the office required notice or missing your appointment will result in a $65.00 fee being applied without exception.
- Any fees must be paid prior to your next scheduled appointment.
- Reminders calls are strictly a courtesy.
- All appointments are considered confirmed at time of booking.
- Please allowed one business day to fulfill Superbill requests.
I understand and agree to the conditions of this policy.
_______________________________________________ _________
Signature of Patient or Legal Guardian if patient is a minor Date
__________________________________________________
Printed Name of Patient or Legal Guardian if patient is a minor
