No-Show and Cancellation Policy Acknowledgement Form

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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.

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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.