I have read and understand the statements that follow:
We schedule our appointments so that each patient receives the right amount of time to be seen by our physicians and staff. That’s why it is very important that you keep your scheduled appointment with us, and arrive on time.
As a courtesy, and to help patients remember their scheduled appointments, Houston Medical Wellness Clinic sends text message and email reminders in advance of the appointment time. You will also receive a confirmation call the day prior to your appointment.
If your schedule changes and you cannot keep your appointment, please contact us so we may reschedule you, and accommodate those patients who are waiting for an appointment. As a courtesy to our office as well as to those patients who are waiting to schedule with the physician, please give us at least 24 hours’ notice.
If you do not cancel or reschedule your appointment with at least 24 hours’ notice, we may assess a
$70 “no-show” service charge to your account. This “no-show charge” is not reimbursable by your insurance company. You will be billed directly for it. After three consecutive no-shows to your appointment, our practice may decide to terminate its relationship with you.
I understand the “no-show” policy of Houston Medical Wellness Clinic and agree to provide a credit card number, which may be charged $70 for any “no-show” of a scheduled appointment. This charge is non-refundable. I understand that I must cancel or reschedule any appointment at least 24 hours in advance in order to avoid a potential no-show charge to the credit card provided.
This card will also be used to pay for my tele-medicine appointment.
I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form.
Please enter card information here, or provide it to the front desk. Thank you!