New Patient Registration Form Page 6

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713-936-2966
Tel:
Srinivas R Panja MD
Fax: 832-698-2236
19701 Kingwood Dr.
425 Holderrieth Street,
920 Medical Plaza Dr
Building 4 Suite A
Ste 108
Ste 350
Kingwood TX 77339
The Woodlands TX77385
Tomball, TX 77375
24 Hour Cancellation & No “how Fee Policy
Each time a patient misses an appointment without providing proper notice, another patient is
prevented from receiving care. As such, each patient is allowed two of the following:
Ca ellatio s less tha
hours’ oti e, No “ho , or arri i g to your appoi t e t ore tha
minutes late. Effective Jan 1
2015 after the second offense office of Greater Houston Diabetes &
st
Endocrinology Center GHDE reser es the right to harge a fee of $ .
for all No “ho
s a d
Ca ellatio s less tha
hours’ oti e.
No “ho
fees ill e illed to the patie t. This fee is ot o ered y i sura e, a d ust e paid prior
o sho s i a y
o th period ay result i ter i atio fro
to your next appointment. Multiple
our practice.
Thank you for your understanding and cooperation as we strive to best serve the needs of all of our
patients.
By signing below, you acknowledge that you have received this notice and understand this
policy.
Printed Name
Date
Signature
Greater Houston Diabetes & Endocrinology Center (GHDE)

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