Cancellation Fee Waiver Request

Cancellation Fee Waiver Request
Please note: Patients must complete their own waiver
POLICIES
CANCELLATION POLICY/NO SHOW POLICY

Cancellations must be made at least 48 hours prior to your scheduled appointment time. We accept cancellations by phone call, text, or email directly to your provider. If not the $100 missed visit fee will apply.

LATE ARRIVALS

If you arrive 15 minutes or more, there might be a chance that your session will need to be rescheduled and you might be charged a missed visit fee
PATIENT INFORMATION
Name*

First NameLast Name
Email*
example@example.com
Birth Date*

MonthDayYear
Parent/Legal Guardian: (If patient is under 18)*

First NameLast Name
Parent/Legal Guardian Email: (If patient is under 18)*
example@example.com
APPOINTMENT CANCELLATION INFORMATION
Today's Date *

MonthDayYear
Date
Date & Time of your Scheduled Appointment*
Date & Time of your Cancellation
Your Clinician's Name*
Please briefly describe the reason you (the patient) are requesting a Cancellation Fee Waiver*
Please upload medical note/doctor excuse:

Cancelof
Patient Signature*
Should be Empty:

Please note: Patients must complete their own waiver