Thank you for choosing BACK IN BALANCE CHIROPRACTIC to provide your chiropractic needs.
When a patient doesn’t make it to a scheduled appointment, this is time another patient could
have taken to receive the care they need. Please help us
deliver the care our patients need as efficiently as possible. Read the following policies, and then sign and
date at the bottom of the page.
CHIROPRACTIC CANCELLATION and NO-SHOW POLICY:
Please be courteous and call our office promptly if you are unable to attend your appointment, we require the you give us at least 24-hour notice so that we have the opportunity to offer your appointment to another patient.
A “No-Show” is someone who misses an appointment without notice. We have voicemail which is able to receive messages 24 hours a day. No-Shows inconvenience patients that are in need of our services.
A failure to cancel a scheduled appointment without 24-hour notice will be recorded in the patient’s file and a cancellation fee of $50.00 will be charged. If you fail to be present for your scheduled appointment you will be charged a “No-Show” fee of $50.00. All fees will be due prior to seeing the doctor at future visits. Further multiple No-Shows may result in suspension of care with BACK IN BALANCE CHIROPRACTIC.
CHIROPRACTIC LATE ARRIVALS
If you arrive late to your appointment, we will do our best to fit you into the schedule, however, it is likely we will reschedule your appointment for another time.I understand the terms of this form. I understand that these fees have nothing to do with my co-pay or deductible and in fact cannot be billed to my insurance company.