GCM_Request to Waive Cancellation Fee

Request to Waive Cancellation Fee
Patient Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Appointment Type*
Original Scheduled Date and Time of Your Appointment *

MonthDayYear
Date
Hour MinutesAM/PM Option
Reason for Cancellation*
If Other, please specify
Please provide a brief explanation for your request:*
Acknowledgment and Notice: By submitting this request, I acknowledge and understand the following:*

A $200 fee may apply to procedure appointments cancelled or missed with fewer than 5 business days’ notice.A $50 fee may apply to clinic or telehealth appointments cancelled or missed with fewer than 2 business days’ noticeSubmission of this form does not guarantee approval of a cancellation fee waiver. All requests are reviewed on a case-by-case basis at the discretion of the practice.Failure to attend a scheduled appointment without prior notice may also result in this fee.If this request is denied, I remain financially responsible for the cancellation fee and any outstanding balances on my account.I confirm that the information provided in this request is accurate and complete to the best of my knowledge.
Patient Signature*
Date*

MonthDayYear
Date

Request to Waive Cancellation Fee