Agreement to Pay No Call - No Show Fee
By submitting this form, the sender authorizes Florida Psychiatry Associates 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 NOT be refunded 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 responsibility of the sender and not covered by insurance.
By clicking "Submit" you agree to honor the terms of this agreement.
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