Sample Dental Appointment Agreement
It is important for patients to keep their dental appointments.
Rescheduling Appointments
We understand that you may sometimes need to reschedule appointments. If you need to
reschedule, please call the clinic as soon as you know that you will not be able to keep
the appointment. Call at least 24 hours in advance.
Missed Appointments
If you miss an appointment or cancel it with less than 24 hours’ notice, a missed
appointment will be recorded in your record. If you are more than 10 minutes late for an
appointment, a missed appointment will also be recorded in your record. Your
appointment may have to be rescheduled if there is not enough time to complete your
procedure. Missed appointments result in lost time that could have been used to provide
care to other patients.
If you have two missed appointments during the past 6 months, you will not be able to make
an appointment for a period of 6 months from the date of the second missed appointment,
unless it is an emergency.
I understand the dental appointment agreement and agree to follow the terms of the policy.
_________________________________________________
Patient Name (please print) Date
_________________________________________________
Patient or Guardian Signature