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PARK CHIROPRACTIC, P.C.
MISSED APPOINTMENT AGREEMENT
Thank you for choosing Park Chiropractic for your chiropractic care. Trying to accommodate
every patient’s individual needs and work schedules can be difficult, but we always try to do our
best. We work very hard to stay on schedule so that our valuable patients will not spend time in
our reception area waiting for an appointment.
A scheduled appointment is a commitment of time between you and our practice. We have
reserved that time just for you. When appointments are missed or cancelled, that time is
permanently lost.
We ask when you schedule an appointment that you make every effort to keep that commitment.
We understand that personal emergencies sometimes occur, and we always take that into
consideration when receiving a last minute cancellation.
In order to provide the highest quality services to our patients, we have enforced a Missed
Appointment Policy. Please review the following agreement and sign at the signature line,
indicating that you understand our policy.
As a patient or guardian for a patient receiving services from Park Chiropractic, I understand and
agree with the following:
• I am responsible for canceling appointments within 24 hours prior to the appointment.
• Should I fail to attend my appointment or cancel my appointment within the 24-hour
period prior to my appointment, Park Chiropractic will notify me of the missed
appointment via letter.
• I will be charged $15.00 for the initial missed appointment and $30.00 for every
following missed appointment.
• Appointments missed due to illness, adverse weather conditions or other conditions that
reasonably prohibited me from canceling the appointment will not be considered missed
appointments. I must notify Park Chiropractic of such an occurrence.
• Park Chiropractic may terminate my services due to noncompliance if I have too many
missed appointments, that is three missed appointments within a twelve-month period
or several missed appointments over a multiple year period. Park Chiropractic will
notify me should noncompliance due to missed appointments result in termination.
Patient Name________________________________________________________
Patient/Guardian Signature_____________________________________________
Date__________________________