No Call Show Form PDF Details

In today's fast-paced world, managing appointments can be a challenge for both patients and healthcare providers alike. The Chiropractic Wellness Center in Fairfax, VA, has implemented a policy to ensure that it can deliver effective and efficient treatment to all its patients. This approach involves the use of a No Call / No Show form, a crucial document designed to minimize disruptions caused by missed appointments. According to this policy, patients are required to cancel their appointments at least 24 hours in advance. Failing to do so, or not showing up for an appointment without prior cancellation, incurs a $25 fee per incident. The form highlights an important aspect; this fee cannot be billed to insurance companies, leaving the patient fully responsible for the payment. The form is clear in its instructions, asking patients to ensure they have no questions and understand the policy fully before signing. This measure is not just about the financial penalty; it’s a step towards fostering a sense of responsibility and respect for the provider’s time and the wellness journey of other patients.

QuestionAnswer
Form NameNo Call Show Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesno call show form, no call no show write up form, no call no show counseling forms, no show fee template

Form Preview Example

CHIROPRACTIC WELLNESS CENTER

9689 Main Street, Suite B

Fairfax, VA 22031

(703) 323-0068

(PLEASE PRINT)

NO CALL / NO SHOW

In an effort to provide effective and efficient treatment to all of our patients, it is the policy of this office that all appointment cancellations are made at least 24 hours prior to your scheduled appointment time.

If an appointment is not cancelled or patient fails to show up for appointment, Chiropractic Wellness Center reserves the right to charge patient a $25 fee per occurrence. As this fee is not billed to any insurance company, patient accepts full responsibility to pay this fee.

If you have any questions about this form, please talk to us before signing.

Patient’s Name: __________________________________________________________

Patient’s / Guardian’s Signature: _____________________________________________

Date: ___________________________________________________________________

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