We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family.  However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment.  Conversely, that situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book.  As of September 1, 2019, if an appointment is not cancelled at least 24 hours in advance you will be charged, in order to book an appointment all clients will be asked to hold their appointment with credit card information.  Your card will not be charged unless you are a NO SHOW!

Cancellation Fees:

New Client $25

Existing Client $25

By reading this form you give us permission to debit your account for the amount indicated on that date.  This is information for a single transaction only, it does not provide authorization for any additional unrelated debits or credits to your account.