A minimum of 48 hours notice is required for all new and returning appointments. Credit card information to be kept on file, including expiration date, CVR code, and billing zip code is required. Signing this form is an acknowledgment that you agree to be charged on this card in the event of a late cancellation or no-show. No-show fee is $90. Two consecutive no-shows/late cancellations will result in a $130 fee.
Credit Card #
Name on card
Zip code of billing address
Insurance will not be billed for missed/canceled appointments.
Your signature indicates that you have read the above and agree to the terms contained therein.
**All fields must be completed in order to successfully submit this form