Reschedule evaluation exception request form

Reschedule evaluation exception request form

It is the policy of JADE Wellness Center to require a 30 day period between any missed evaluation or evaluations not cancelled within 24 hours. If you would like to request an exemption due to a last minute emergency or hardship that caused you to miss your appointment please complete the fields below.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Which site was your assessment scheduled at?

MonroevilleSouthsideWexfordTelehealthUnsure
What was the date of your missed assessment/evaluation?

MonthDayYear
Date
Please specify why you did not attend this assessment or cancel/RS within 24 hours of your appointment.
The infromation above will be sent to one of our clinical directors to review within 72 hours. A team member will let you know the determination of your request upon its review.

Thank you,
Should be Empty: