Miss No-Show

Chiropractic, Massage, Trigger Point Therapy, Salt Cave and more!
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Miss No-Show 

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KELLY Family Chiropractic Office

Dr. Janine D. Kelly
1762 Newbridge Road
Bellmore, NY 11710
(516) 409-0044

MISSED/No-Show Appointment POLICY

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.