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Monday, December 12, 2011

Reducing Patient No Shows and Cancellations

Below is a copy of a commitment form that we have patients sign at their first appointment in our office.
By making patients aware of our policy we have seen our last minute cancellations and no shows drastically reduced.

Feel free to copy the content below and use it for you office or email me at and I will email you the file.

Name: __________________________________ E-mail Address _______________________

Home ( ) ___________________________ Work ( ) _____________________________

Cell ( ) _____________________________ Other ( ) ____________________________

Emergency Contact: _________________________________ Phone: _____________________

Our Commitment

At __________________, we are committed to excellence. We feel that you deserve nothing less when it comes to your health. We use the best materials and techniques available in order to provide you with the quality you have come to expect from us.

We believe that our relationship with you, as with all relationships, needs open and clear communication. We will try to communicate all of your dental needs and estimate your financial information as soon as it becomes evident. We want you to be as informed as possible to help you in your decisions concerning your dental health.

We understand how valuable your time is, so we make every effort to remain on time. We do not double book our appointments. We feel that you deserve our complete and focused attention so that we may provide the best care possible. Your reserved time is exclusively yours.


Your Commitment

We want you to be comfortable with our team. If you ever have any questions about your dental treatment, financial or insurance questions, or any concerns at all, we ask that you notify us as soon as possible. We will be glad to clarify any uncertainties that may arise.

Your portion of your treatment is expected at the time of your services. For your convenience we do accept many forms of payment including, cash, check, Visa, Mastercard, American Express, and we also offer third party financing, which includes both interest free programs and extended financing.

Your scheduled appointment is reserved exclusively for you. We have a 48 hour cancellation policy in order to provide you with this personalized attention. We understand that circumstances may arise that require an appointment to be rescheduled. We are happy to change your appointment time if a 48 hour notice is given. If sufficient notice is not given, your account will automatically be charged a $50 missed appointment fee. We ask that you make every effort to keep your reserved time.

Patient/Guardian: _________________________ Team Member/date:___________

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