No show, Late Cancellation
and Financial Policy
⦁ I understand that I will be charged a LATE CANCELLATION fee of ($150.00) if I fail to give at least 24 -hour notice prior to cancelling my appointment.
⦁ I understand that I will be charged a NO SHOW Fee of ($300) if I fail to attend my initial visit (for new patients only), and that Dr. Ngalame can only reschedule me if I request an appointment by paying the fee of $300 for my new visit in advance of the appointment, on the day it is scheduled.
⦁ I understand that these above mention charges are out of pocket expense and that my insurance carrier will not cover them. I further understand that it is my responsibility to pay these charges.
⦁ I understand that my NO-SHOW/LATE CANCELLATION fee is due within (2 days) of missed appointment, and that my credit on file will be charged.
⦁ I understand that the initial session will last (60 minutes), and the follow up session will last (30 Minutes). I understand that if I am late to the appointment, I will still have to end the session at the allotted time. By signing this, I am agreeing to the above stated terms and stipulations regarding the services I receive from this practitioner.
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Name of Responsible Party
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Signature of Responsible Party
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Date