smilesolutionsdmd.com - Dental Hygiene

1. Date of last dental cleaning?

Date

What was the name of the office or dentist?

2. How often do you brush?

YesNo

Practice Name: Smile Solutions DMD
Address: 2221 Transcontinental Dr. Suite G, Metairie, LA 70001 Phone: (504)-613-5100
Email: Smitesolutionsdmd@gmail.com

Patient Information

Full name

Date of birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Cancellation Policy

We understand that sometimes schedule adjustments are necessary. However, we require at least 24 hours notice for appointment cancellations or rescheduling.

Appointments canceled with less than 24 hours may incur a cancellation fee of $75.00.
Missed (no-show) appointments without any notice will also be subject to a fee.
Repeated cancellations or no-shows may result in limitations on future bookings.

Acknowledgment and Signature
I understand and agree to the terms of the cancellation policy stated above. I acknowledge that failure to provide sufficient notice or missing appointments may result in fees or scheduling restrictions.

Patient Signature

Date

Dental Hygiene

Smile Solutions DMD Appointment Cancellation Policy Form