carolinaforestdentist.com - Fee Waiver Request Form

Cancellation Fee Waiver Request Form
Dear Valued Patient,

We understand that unexpected events can arise, and we strive to accommodate our patients as best as we can. If you have missed or need to cancel an appointment due to extenuating circumstances beyond your control, please complete this form to request a waiver of the cancellation fee. Each request will be reviewed on a case-by-case basis by management. This process is designed to ensure that everyone is treated fairly and has an opportunity to have their situation reviewed without the appearance of bias among staff members.
Patient Information:
Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.
Email Address:
example@example.com
Appointment Details:
Date of Scheduled Appointment:

MonthDayYear
Date
Time of Scheduled Appointment:

Hour Minutes

AM/PM Option
Extenuating Circumstances (please check the reason that applies and provide a brief explanation):

Medical EmergencySevere Illness (self or immediate family)Family EmergencyInclement WeatherOther (please specify):
Explanation:
Supporting Documentation (if available, please attach any relevant documents, such as a doctor’s note, accident report, etc.)

Cancelof
Supporting Documentation:

AttachedNot available
Acknowledgment: By signing below, I certify that the information provided is accurate and truthful. I understand that submitting this form does not guarantee a waiver, and the decision will be at the discretion of the dental office.
Patient Signature:

Clear
Date:

MonthDayYear
Date
Office Use Only:

Request Received By: ___________________________
Date Received: ________________________________
Decision: [ ] Approved [ ] Denied
Notes: __________________________________________________________________
Thank you for your understanding and cooperation.

Sincerely,

Ownership

Beach Family Dentistry
Should be Empty:

Cancellation Fee Waiver Request Form

Patient Information:

Appointment Details: