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Cancellation Policy Form

We do understand that emergencies and scheduling conflicts do come up from time to time. However,we request that you please notify us and change your appointment at least 48 business hours before your appointment.

If you change your appointment within 48 business hours, there will be a $50 non-refundable cancellation fee. This fee is assessed to cover the cost required to prepare and set up for your appointment. We will ask for payment over the phone or send you a payment request via text message. We will also send you a copy of this policy.

On the third cancellation we will ask that you prepay for your appointment time in full. If a fourth cancellation occurs, we will no longer reserve appointments for you. You will be able to call or come to the office and we will attempt to work you into our schedule.

Thank you for respecting and understanding our policy so we can have a well run small business for our staff and be prepared for our patients in a timely manner.

Dalton C. Hunt and Mark L. Helms

I have read and understand the above policies.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.