Cancellation Policy Form

We plan our schedule carefully in order to provide enough time and attention for each patient's dental needs. Many times our patients wait weeks for an appointment. As a courtesy and in order to assist you in remembering your appointments, we place a reminder call a few days in advance. We do ask that you return our call to confirm or to make a change to your appointment.

When patients fail to cancel an appointment, it does not allow us to schedule other patients who are waiting to get into our schedule sooner. If your schedule changes and you cannot keep you appointment, pleas contact us. Out of courtesy to all of our patients, we ask that you give us a least 2 business days' notice if you need to change your appointment. There is a standard fee for last minute cancellations and broken appointments.

We appreciate your attention on this matter and look forward to serving your dental needs.

Signature

I have read and understand the cancellation policy of this office (David M Iadarola DMD). I understand that if I cancel and/or reschedule any appointment, I will give the office a minimum of 2 business days' notice

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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