M.D. CLAIBORNE & ASSOCIATES, L.L.C.

NO SHOW/CANCELLATION POLICY FORM


To Our Patients:

M.D. Claiborne & Associates, L.L.C. is committed to helping you manage and maintain your skin care needs. When you schedule an office visit or surgery appointment with our physician or laser specialist, that time is reserved exclusively for you. If you know that you will be unable to keep your office visit, surgical or cosmetic appointment, we ask you to show considerat ion by calling our office in advance. Providing our office with adequate notice will allow us to offer that appointment time to another patient. We do understand that on occasion unforeseen circumstances do arise and the need to cancel your office visit or scheduled surgery without advanced notice may be unavoidable. We will address those situations with you when and if they arise.
 

In the event you do not cancel/reschedule your office visit, scheduled surgery or cosmetic appointment, the following fee will be applied to your account:
 

All fees applied to your account will require payment in full prior to scheduling any future appointments . If fees are not paid, your account will be placed with an outside collection agency.

Please note: these fees are not billable to your insurance carrier and are the patient's responsibility. Per your carrier and the contract agreement with the physician these fees are permissible and collectable.

We thank you for working with us to ensure that services are provided to all our patients in the best manner possible. Please contact the Office Manager for any questions you may have regarding this policy.


AGREEMENT

I have read and understand the no show/cancellation policy of the practice and agree to be bound by the terms as stated . I also understand the practice reserves the right to amend this policy as needed.

 

Please sign to acknowledge that you understand and agree:

Reset Signature

 Please type your full name to acknowledge that you understand and agree: