Cancellation Policy Form Name Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone Work Phone Cell Email Address We at Agape Dentist make every effort to provide a convenient appointment time for you which suits your work and personal schedule. Our practice guidelines for missed or broken appointments. You will receive a courtesy reminder call, text message, or email from our office for appointments scheduled. These advanced reminder notices will give you enough time to make any necessary changes. If you or a family member cancel a scheduled appointment within 48 hours, a charge of $80.00 will be placed on your account. This notification is for your convenience. We understand that emergencies do occur and your oral health is of utmost concern to us. We know that very few of you will be affected by these guidelines since almost all of you either keep your appointments or call to reschedule well in advance. We thank you for your understanding our practice guidelines. Patient or responsible Party Signature: Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
