APPOINTMENT AGREEMENT. I understand that my appointment times are being reserved for me and that efficiency of scheduling often depends on my keeping my appointment as scheduled. I understand that repeated missed appointments may delay my treatment progress and failure to cancel 24 hours before an appointment is considered a no-show.
APPOINTMENT AGREEMENT. Welcome to our practice. We are honored that you have selected us for all of your dental needs. We are committed to providing quality services to our patients and believe that an important aspect of delivering exceptional dental care is our patients' commitment to our practice as well. Therefore, we request that you honor your reserved appointment as scheduled. Should you have to change your appointment for any reason, we ask that you give us 24 business hour notice. Because missed appointments increase the cost of healthcare for everyone, should you miss two appointments in which 24 hour notice is NOT given, a $75.00 fee may apply. We appreciate your understanding in this matter. WRITTEN FINANCIAL POLICY We are committed to making the cost of your dental care easy and manageable by offering several payment options. You can choose from: Cash , Check, Visa, Mastercard, Discover and Care Credit We offer a 5% courtesy accounting adjustment to patients that pay for their treatment in full with cash or check ( 10% for seniors, 65 years and older) For plans requiring multiple appointments, alternative payment arrangements may be provided. All charges you incur are your responsibility regardless of insurance coverage. As your dental care provider, our relationship is with you, not your insurance company. We can only estimate what an insurance company says benefits will be. As a courtesy we will help you process your insurance claims. All co-pays and/or out of pocket expenses are due at the time services are rendered unless other arrangements have been made. Returned check and/or balance over 90 day may be subject to finance charges of 1.5% per month (18% annually). All accounts that are turned over to a Collection Agency will also be subject to additional fees. If you have any questions, please do not hesitate to ask. We are here to help. ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
APPOINTMENT AGREEMENT. We ask when you schedule an appointment that you make every effort to keep that commitment. We understand that personal emergencies sometimes occur, and we always take that into consideration when receiving a last minute cancellation. If you find that you cannot keep your scheduled appointment, we ask you to provide a minimum of 2 business days notice to us so we may schedule another patient in need of treatment. For your convenience, our office hours are Mondays and Wednesday from 10:00 a.m. to 7:00 p.m., and Fridays from 10:00 a.m. to 6:00 p.m. All cancellations and reschedules must be done by calling the office, it cannot be done by text or email at this time. It is our policy that with less than 2 business days notice a failed appointment charge of $40.00 or 20% of the scheduled amount, whichever is larger, will be applied to your account. If you have any questions regarding this policy please do not hesitate to contact us. We sincerely appreciate your understanding and cooperation with this matter. __________________________________________ _______________________ Patient Signature Date NOTICE OF PRIVACY PRACTICES: Acknowledgement of Receipt By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Xx. Xxxxxx Xxxxxx, Jr. D.D.S. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully. Our Notice of Privacy Practices is subject to change. I acknowledge receipt of the Notice of Privacy Practices of Xx. Xxxxxx Xxxxxx, Jr. D.D.S. Signature: ___________________________________________ Date:_____________________ (patient/parent/conservator/guardian) FOR OFFICE USE ONLY INABILITY TO OBTAIN ACKNOWLEDGEMENT To be completed only if no signature is obtained. If it is not possible to obtain the individual’s acknowledgement, describe the good faith efforts made to obtain the individual’s acknowledgement, and the reasons why the acknowledgement was not obtained: Signature of provider representative:_________________________________ Date:__________ Reasons why the acknowledgement was not obtained: ? Patient refused to sign. Other or Comments: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Dental Materials Fact Sheet Dental Material Data Fact Sheet: Ac...
APPOINTMENT AGREEMENT. We respect the importance of your time and work very hard to schedule appointments that accommodate the busy scheduling need of all our patients. We offer appointment reminders by email, text and phone calls. Broken or missed appointments create a problem for those patients who need our services. Email: ___________________________________________________________________________________ Text: _______________________________ Reminder Call: __________________________________ __________ (initial) Therefore, we require a 48-business hour cancellation notice for any appointment changes that may occur. A charge of $50.00 per scheduled appointment hour will be applied for non-notification in this matter. Thank you for your cooperation.
APPOINTMENT AGREEMENT. I agree to notify MN at least 24 hours (or one working day) in advance if necessary for me to cancel a psychotherapy appointment. If I miss an appointment without appropriate notification (24 hours or one working day), unless we reach a different agreement, the full fee of will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions. Signature Date Witness Date
APPOINTMENT AGREEMENT. The Administrative Agent shall have received an execution copy of the Appointment Agreement.
APPOINTMENT AGREEMENT. We understand that your time is very valuable. We are constantly striving to make your experience here a pleasant one. Trying to accommodate each patient’s individual needs and work schedule can be challenging. We make every effort to stay on time so that our patients will not have to wait unnecessarily. Your appointment is a commitment of time between you and our office. We ask that you make every effort to keep that commitment. We do provide a courtesy reminder call two to three days prior to your appointment. If you cannot keep your appointment, we do require a minimum notice of 48 business hours so we are able to assist other patients with their dental needs. If our office is not notified within 48 business hours, you will be subject to a $50 late cancellation charge. We truly appreciate your understanding. Our goal is to be your partner in health and to assist you in keeping your teeth for a lifetime. I HAVE READ AND FULLY UNDERSTAND THE APPOINTMENT AGGREEMENT SET FORTH AND I AGREE TO THE TERMS OF THIS AGREEMENT.
APPOINTMENT AGREEMENT. Simultaneously with the execution of this Agreement, Vendor shall execute each of the Agreements for Removal, Appointment and Acceptance in the forms attached hereto as Exhibit “4” and “5” hereto. If Vendor is the current Indenture Trustee under the HRA Trust Indenture and the current Master Trustee under the PLA-CLA Trust Indenture, this paragraph does not apply.
APPOINTMENT AGREEMENT. We set aside a reasonable amount of time for your appointment with the Doctor so that you are properly examined and all of your concerns are handled. We ask that our patients be courteous and call our office 48 hours in advance if appointments cannot be kept. If an appointment is canceled without proper notice, a fee WILL be assessed to your account.
APPOINTMENT AGREEMENT. The terms and conditions of every appointment, whether 24 tenured, tenure track, visiting or lecturer, shall be stated or confirmed in writing, and a copy 25 of the appointment agreement will be supplied to the faculty member concerned. Any 26 subsequent extensions or modifications of an appointment, and any special understandings, 27 or any notice incumbent upon either party to provide, will be stated or confirmed in writing 28 and a copy will be given to the faculty member concerned. 29
