Appointment Cancellation Policy
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: _______
Billing Zip Code: _____________________
Print Patient Name: __________________________________
Patient Signature: ____________________________________ Date: ___________