• SPRAVATO® (ESKETAMINE)

  • No-Show & Late Cancellation Policy

  • Practice Name: Dallas Child, Adolescent & Adult Psychiatry
  • DOB*
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  • Purpose

  • Spravato treatment requires:
    • Special medication ordering and handling
    • Reserved clinical staff monitoring for a minimum of 2 hours
    • Dedicated treatment room scheduling
    • REMS program compliance documentation
    Missed appointments significantly impact clinic operations, medication management, and other patients awaiting care.

  • Cancellation Notice Requirement

  • Patients must provide at least 12 hours notice (recommended: 24-48 hours) to cancel or reschedule a Spravato appointment.
    Notice must be given by:
    • Calling the office at 972-473-7444
    Voicemail timestamps determine cancellation timing.

  • No-Show Policy

  • A No-Show is defined as:
    • Failure to attend a scheduled appointment
    • Arriving more than 15 minutes late and unable to complete treatment
    • Failure to remain for required 2-hour monitoring
    • Failure to have appropriate transportation arranged

  • No-Show Fee:

  • $50 per occurrence

  • Medication & REMS Considerations

  • Spravato is:
    • A Schedule III controlled substance
    • Ordered and prepared specifically for scheduled treatment days
    • Governed by federal REMS requirements
  • Repeated missed visits may:
    • Disrupt dosing schedules
    • Affect clinical outcomes
    • Result in REMS noncompliance

  • Repeated Missed Appointments

  • The following may result in treatment discontinuation:
    • Two (2) late cancellations
    • Two (2) no-shows
    • Pattern of inconsistent attendance
    • Failure to comply with transportation policy
  • The provider reserves the right to suspend or discontinue Spravato treatment if attendance requirements are not met.

  • Financial Responsibility

  • No-show and late cancellation fees:
    • Are not billable to insurance
    • Must be paid prior to rescheduling future treatment
    • Do not replace any outstanding balances
    Unpaid fees may delay or prevent scheduling of future treatments.

  • Emergency Exceptions

  • Fees may be waived at the sole discretion of the provider for:
    • Medical emergencies
    • Severe weather conditions
    • Documented urgent circumstances
  • Supporting documentation may be required.

  • Patient Acknowledgment

  • I understand that Spravato treatment requires strict scheduling and monitoring. I agree to comply with this No-Show & Late Cancellation Policy and understand that repeated violations may result in discontinuation of treatment.
  • Date:*
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