Agreement to Pay No Call - No Show Fee
By submitting this form, the sender listed above does hereby;
1) authorize JoAnna VanVleet, D.O. LLC. to apply a one time charge of $100.00 to their credit card for the purpose of securing an initial appointment.
Both parties agree this fee will be charged only if the sender books an appointment and does not show up, or calls less than 24 hours prior to their appointment to cancel or reschedule. It is also understood this No Call - No Show Fee is the sole responsibility of the sender, as it is not covered by any insurance company and as such, will not be reimbursed.
By clicking "Submit" you agree to honor the terms of this agreement.
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