Simplex Health Appointment Cancellation Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out this form in its entirety to confirm your cancellation of your appointment. Cancellation requests must be received more than 24 hours prior to your scheduled appointment. If you wish to call to cancel, please contact us at 877-842-2425.

***any cancellation requests received with less than 24 hour notice may result in a $45 late fee***

Patient's Full Name *

The date of the appointment that you wish to cancel (please keep in mind of our cancellation policy) *

YYYY

A phone number where you can be reached *

What is the reason for your cancellation? *

I wish to reschedule at a later date

I have a high copay

I have a High deductible or coinsurance

I am not satisfied with Simplex Health Services

I had an unexpected circumstance or emergency come up

I just don't have the time right now, but I am still interested

Other:

What is the name of your dietitian? *

I understand that if I am cancelling with less than 24-hour notice, I am subject to a late cancel fee. *

Yes

Anything else you'd like us to know?

To reschedule, please give us a call during regular business hours at 877-842-2425. Our office hours are 8:30 AM -5:00 PM ET, Monday through Friday. Any cancellation requests submitted outside of business hours will be addressed the following business day.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Simplex Health.

Does this form look suspicious? Report

Forms