1. Patients who wish to cancel or reschedule appointments are asked to do so by NOON the business day prior to the appointment.
2. Patients who fail to keep appointments, or who cancel on short notice, two or more times are subject to a $50 broken appointment fee, or discharge from the practice, at our discretion. The broken appointment fee is to be paid prior to scheduling appointment, and is non-refundable.
3. If you are enrolled in a managed care plan, your insurance carrier will be notified of your no-show/tardiness record with our office.

Please note: This document is not a permission slip. By signing this document, you are recognizing that this the the appointment policy for this office, and that you understand the policy.

1. Call you at home and leave a message on your answering machine? Yes or No

2. May we leave a message with anyone who answers the telephone regarding
   your appointment, condition, or medical information? Yes or No

Monday 8:30 a.m. to 5:00 p.m. Dover 1:30 p.m. to 5:00 p.m. Milton Tuesday 8:30 a.m. to 5:00 p.m. Dover Wednesday 8:30 a.m. to 5:00 p.m. Dover Thursday 8:30 a.m. to 5:00 p.m. Dover 9:00 a.m. to 5:00 p.m. Smyrna Friday 8:30 a.m. to 4:00 p.m. Dover

Signature _________________________________ Date __________________