Please sign your name at the bottom of this form.
We understand that there are times when you must miss an appointment due to an emergency. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book. If an appointment is not cancelled at least 24 hours in advance you will be charged for the full cost of your appointment ($295 for an Initial Consultation, $495 for a Mood Infusions, $1750 for a Pain Infusion). If you more than 15 minutes late for your scheduled appointment time, we will be forced to reschedule and charge you for a no-show appointment. All patients are required to keep a valid credit card on file with the clinic. Please let us know of any changes in payment information. I have read and understand Mind Peace Clinic’s Cancellation Policy.
Date of Signing
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