Cancellation Form:

* Please note that cancellations without at least 24 hours notice will be subject to a fee not covered by insurance.

* You may still receive automated text messages about your cancelled appointment, but you may disregard them.

Patient's Name

First Name

Last Name

Cell Phone

(###)

###

####

Date of Your Appointment

YYYY

Appointment Time

Cancellations With Less Than 24 hours Notice

Missed Consult: $150. Missed Surgery: $500

I accept the missed visit fees associated with any cancellation with less than 24 hours notice.