Chiropractic Appointment Reminder Letter Template (Page 3 of 9) in pdf

Chiropractic Appointment Reminder Letter Template Page 3

MISSED APPOINTMENTS:

A 24 hour cancellation policy is in effect for all chiropractic services.

We reserve the right to charge for missed appointments. If 24 hour

notice is not given, you will be billed $30.00 for the session. If you have any

questions about our Financial Policy you may direct them to Kendra, the

Financial Coordinator.

I have read the Financial Policy. I understand and agree to this Financial

Policy. I authorize Linda Berry, DC or Kathleen Dvorak, DC to provide care

for the examination and treatment of my case. I am ultimately responsible

for all charges incurred, including any collection efforts or court fees. I

hereby consent to any statements stated above, that apply to my situation.

Copies of these statements are as legal and binding as the original.

_____

Signature/Date: ___________________________________________

Consent to Treat a Minor

I hereby authorize the doctor to treat my son or daughter.

Name of child: __________________________________________________

Name of Parent/Guardian: _____________________________Date: _______

Chiropractic Appointment Reminder Letter Template Page 3