Broken Appointments. The Employer will log all broken appointments received by one or more of the following: telephone, email, facsimile, letter and card from the person occupying the dwelling, and should the number be higher than 5% of all appointments in any one calendar month, a payment in accordance with the terms of the Contract for every broken appointment will be recoverable from the Contractor. The Contractor must ensure that all appointments are kept and failure to do so or unnecessary cancellations by them could result in termination of the Contract.
Broken Appointments. Appointments not kept or rescheduled with less than two business days’ notice are considered broken appointments. Please be considerate and inform us in advance if you need to reschedule your appointment. We reserve the right to charge a minimum of $108 for broken appointments. We understand temporary financial problems may affect timely payment of your balance. In those situations, we encourage you to communicate any such problems immediately so that we may assist you in the management of your account. CONSENT & AUTHORIZATION: I agree to pay all related fees. Fees not covered by my dental insurance will be promptly paid upon notification from this office. I have read and understand this document, outlining financial policies of Drs. Xxxxxxxx & Xxxxxxxx D.D.S., P.A. I agree to abide by the policies outlined herein. Patient Name: Signature: Date: **If applicable, name and relationship for dependent: Guarantor’s Name Relationship to patient
Broken Appointments. If unable to keep a scheduled appointment, we require 24 hours notice. The second time an appointment is broken, there will be a $25 charge. Repeated missed appointments may result in dismissal from the practice. Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. Responsible Party Signature: Date:
Broken Appointments. If you miss a scheduled appointment or cancel it at the last minute, a broken appointment will be recorded in your dental chart. If you are more than 10 minutes late for an appointment, this will be considered a broken appointment, a broken appointment will be recorded, and you may have to be rescheduled if there is not enough time to complete your procedure. It is not fair to keep other patients waiting because someone showed up late. If you acquire 2 broken appointments, you will not be able to make a regular appointment for a period of 6 months from the date of the second broken appointment. You are still eligible for emergency dental care during that time, but you will be required to come in to the office in person, and will have to wait until we are able to see you if possible. If you have 3 broken appointments, we will no longer be willing to see you for regular dental care, and you will need to contact a local dental referral service, regional dental society, or the yellow pages of your telephone book to find another dentist for your treatment. I understand the Dental Appointment Agreement and agree to follow the terms of the broken appointment policy. Patient Name (please print) Date Patient or Guardian Signature
Broken Appointments. ODRC agrees to keep a record of all broken dental appointments and on a regular basis ascertain the most frequent reasons for such broken appointments. Each institution, at least annually during the life of this Agreement, will prepare an action plan designed to reduce the number of such broken appointments. Such plan will be reviewed and subject to comment by class counsel and the DOC.
Broken Appointments. If you miss a scheduled appointment or cancel it less than one hour prior, a broken appointment will be recorded in your chart. If you are more than 15 minutes late for an appointment, a broken appointment will also be recorded, and you may have to be rescheduled if there is not enough time to complete your visit. It is not fair to keep other patients waiting because someone showed up late. If you have three broken appointments during the past six months, you will not be able to make a regular appointment for a period of six months from the date of the third broken appointment. If you require medical or dental services during those six months, you may come and wait for an open appointment. I understand this Appointment Agreement and agree to follow the terms of the broken appointment policy. Patient Name (please print) Date
Broken Appointments. We reserve the right to charge $25.00 for appointments cancelled or broken without 24 hours notice. This charge must be paid before another appointment can be scheduled. Arriving 15 minutes or more after your scheduled appointment could result in rescheduling your appointment and a broken appointment charge. 2 MISSED APPOINTMENT occurrences will result in discharge from our practice.
Broken Appointments. A specific amount of time is reserved especially for you, and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 48 hours’ notice to avoid a $100.00 cancellation fee (emergencies are an exception).
Broken Appointments. An appointment is a time reserved for a patient with Xx. Xxxxx and his team to provide dental care. Please allow at least 24 hours advanced notice when cancelling or rescheduling an appointment. Any appointment that is cancelled or rescheduled with less than a 24 hour notice will be considered a broken appointment. An office visit fee may be imposed for a broken appointment. Repeated broken appointments may result in dismissal from our office. Thank you for taking the time to read and understand our Patient Agreement. Please let us know if you have any questions or concerns. We are committed to providing you with a positive dental experience. X Date
Broken Appointments. When you make an appointment, we reserve an increment of time to minimize time spent waiting to see the physician in our office. When a patient misses their appointment, it takes away precious time the physician could be spending treating another patient. As a result, IENT/UHB reserves the right to charge a $30 fee for standard appointments and up to $75.00 for extended services including but not limited to in office procedures, CT, Audiology testing, dizziness workups, etc. that are not cancelled with a 24 hour notice. BY SIGNING, YOU INDICATE THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO THESE TERMS, YOU HAVE RECEIVED A COPY OF THIS DOCUMENT, AND THAT YOU ARE THE PATIENT, THE GUARANTOR, THE PATIENT'S LEGAL REPRESENTATIVE, OR LEGALLY AUTHORIZED TO SIGN THIS AGREEMENT AND ACCEPT THESE TERMS. Patient Name (PLEASE PRINT) Date
