Appointment Request Form

Name of Dentist: *

First NameLast Name

Dental Office Name:

Name & Title of Person Cancelling the Assignment(s): *

Dental Office Email: *

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number to reach you:*

Please enter a valid phone number.

Type of Temporary Cancelling*

Date(s) & Hours Cancelling Temporary:*

* ONLINE Cancellations require a 2 day business notice, or all fees will apply.

Reason for Cancellation:*

Is there any additional information we need to be aware of?:

Cancelation Policy: Once a Temporary has been scheduled to fill-in in your office, a 24- hour business day cancellation by phone is required; any online cancellations requires a 2 business day notification (48 business hours). All cancellations must be done by 10 am Central Standard Time (CST) to avoid fees. Anything less than 24 hour business day notification by phone the dentist/ employer will be responsible for paying the Temporary a 5 hour minimum and will be responsible for the Cancellation Fee to Daily Dental Solutions, inc. Fees will be based on current Temporary Placement Fee Schedule. The latest a cancellation can be made to avoid fees is by 10 AM the business day prior to the day of placement by phone. Onlince cancellations must be submitted 2 business days before the date of the assignment by 10 AM CST. NO EXCEPTIONS. Please note our office will be closed for all major holidays. Any cancellations surrounding a holiday must be made the business day prior to the holiday by 10 am CST. If your office has requested a Temporary and you no longer need the Temporary it is your responsibility to call and cancel it by 10 AM CST the business day prior to the day of placement. All assignments are worked on until covered.

Cancellation Form