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Medical History & Consent
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Confirmation

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June 2023

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Your Details

Insurance / Payment Details

Please note: Charges apply for no-shows or cancellations without 24-hour notice.

Medical History & Consent

Appointment Summary

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Appointment Booked Successfully!

Thank you for booking with us. We've sent a confirmation email with your appointment details.

We look forward to seeing you soon.

Important Details

Key Information

Please Read The Following Information Carefully

Initial Visit

Please plan to arrive on time so that we can complete your records. Share your medical insurance card, pertinent medical records. Prior psychological test reports, and any rating scales or questionnaires.

Cancellation Policy

In today’s hectic world unplanned issues come up for all of us. We recognize this fact, but we respectfully request that you cancel your scheduled appointment by phone a minimum of 24 hours in advance. That way the open slot can be filled with someone needing an appointment.

If you do not cancel by the deadline, you will be assessed a $50.00 missed appointment fee. This fee is not covered by insurance carriers or Medicare/Medicaid and will be your responsibility to pay before your next visit. Your cooperation and consideration are appreciated as we institute this new policy.

Most of the time we remind our patients a day before their appointments but we are not obligated. Therefore, it is the patient’s responsibility to keep track of his/her appointment.

Rescheduling Appointments

We understand that situations may arise requiring you to change your appointment.

Please notify our office at least 24 hours in advance if you need to reschedule.

Appointments rescheduled with less than 24 hours’ notice may be considered a late cancellation.

Repeated rescheduling (more than two consecutive times) may result in limited scheduling options or a review of your care plan.

Cancellations

Cancellations must be made at least 24 hours before your scheduled appointment to avoid a fee.

Cancellations made within 24 hours of the appointment time may be subject to a late cancellation fee (e.g., $25–$75, depending on visit type).

If you are using insurance, please note that insurance does not cover cancellation or no-show fees.

No-Show (Missed Appointments)

A “no-show” occurs when a patient does not attend their appointment and fails to notify the office in advance.

No-shows may be subject to a no-show fee (e.g., $50–$100).

After two or more no-shows, the practice reserves the right to:

  • Require prepayment for future visits, or
  • Discharge the patient from the practice after appropriate notice.