No-Show and Cancellation Policy Acknowledgement Form
Acknowledgment of First-Time Waiver
Regarding your recent appointment, which resulted in a no-show or a cancellation with less than 48 hours' notice, we are extending a one-time courtesy. As this is considered your first instance of such an occurrence, we are waiving the standard $65 no-show fee for this appointment.
By signing below, you acknowledge that:
You have received and read the No-Show and Cancellation Policy of Warrington Dental Arts, which requires a minimum of 48 hours' notice for any appointment cancellation or rescheduling.
You understand and agree to adhere to this policy for all future appointments.
You understand that while the fee for your first missed appointment is being waived, all subsequent missed appointments or cancellations without 48 hours' notice will incur the $65 fee, which must be paid before new appointments can be scheduled.