Office Policy & Consent Form

A reserved appointment time in any dental office is limited and valuable. It is extremely important that all
our patients honor their reserved dental appointments.

Those who fail to keep their scheduled appointments should not penalize the Dentist, our staff, and mainly
our other patients. Our dental policy stipulates that failure to give sufficient notice to keep a scheduled appointment will result in a fee being charged. That charge is in accordance with our dental office’s broken
appointment policy for all of our patients. The patient is responsible for the payment of the charge.

• Cancellation or rescheduling of an appointment with 48 hours’ notice or more notification – NO CHARGE
• Cancellation, rescheduling, or failure to show-up for a scheduled appointment with less than 24 hours’
  notice will be charged the following:

$25 FOR ALL APPOINTMENTS

After a third missed or canceled appointment without 24-hour notice, the patient may be dismissed from the
practice at our discretion.

Every effort is made to contact patients to confirm. Our staff will contact you 1 days prior to your scheduled appointment to confirm with you. Please understand that this is a courtesy call, text, or email. If we are unable to reach you, your appointment texts or emails will serve as your confirmation of the appointment and implies your obligation to be present.