In order to accommodate all of our patient’s needs, we require 24 hour notice if you cannot keep the appointment we have reserved with our hygienist or doctor. A fee of $50 will be charged for no show appointments or appointments cancelled with less than 24 hours notice. We understand emergencies do occur and we do not wish to penalize patients for unavoidable situations. We appreciate your understanding of the need for this policy.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.