Miss No-Show Chiropractic, Massage, Trigger Point Therapy, Salt Cave and more!Let us help you achieve your health goals! BOOK AN APPOINTMENT Miss No-Show Leave this field blank KELLY Family Chiropractic Office Dr. Kelly's Grotto (optional) Dr. Janine D. Kelly1762 Newbridge RoadBellmore, NY 11710(516) 409-0044 MISSED/No-Show Appointment POLICY Date Credit Card #: Expiration Date Note: I understand & agree that I am personally responsible for payment for appointments missed without notice in advance, and that it is not the responsibility of the insurance carrier or any third party payor to make payments on my missed appointments. I also understand my Card will be charged the fee of $25.00 dollars if I do not call, cancel or show for my appointments on the same day. If I have an yunderstanding balances on my account due BY ME, this card can be used to clear my balance due as well. I will receive a receipt for payment. A copy of this form shall be as valid as original. I agree above mentioned terms. Patient Signature Start Drawing Clear Done Start Over Send
