Appointment Cancellation Policy

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I acknowledge my appointment for __________________ must be held with a valid credit card. Cancellation or change of appointment must be made 48 hours in advance. We reserve the right to charge 10% of the total fee for any missed appointments. The approximate fee for my appointment on ___/___/___ is $__________.

Issuing Bank: _______________________________________

Name on Card: ______________________________________

Card Number: __________________________________ CVV Code: _______

Expiration: __________________________

Billing Zip Code: _____________________

Print Patient Name: __________________________________

Patient Signature: ____________________________________ Date: ___________