Cancel An Appointment

*Please note, all office visits require one full business days’ notice to avoid a $50 cancellation fee. All procedures require 3 full business days’ notice to avoid a $250 cancellation fee*

Full Name

Phone Number

Date of Birth

Appointment Date

Reason for Cancellation

Would you like a scheduler to contact you to reschedule your appointment?

YesNo

Please check this box if you are scheduled for an office visit and due to sickness would like to change this to a telehealth visit:

*Please note, we do require proper notice to change someone to telehealth. A scheduler will be contacting you prior to cancelling your appointment in an effort to change your appointment to a telehealth visit, depending on how much notice we have, depends on if this can be changed.

YesNo

By submitting this form you are confirming that you would like to cancel your scheduled appointment. Please note if requesting to change to a telehealth appointment, a scheduler will attempt to call you before canceling your appointment. If we are unable to get ahold of you, your appointment will be cancelled. This online request will include a time and date stamp as to when you have requested to cancel. As long as you are cancelling within the above guidelines, you will not be charged a cancellation fee. Anyone scheduling outside of these guidelines, will be reviewed prior to rescheduling to determine if a fee is charged. If requesting to reschedule, a scheduler will be in touch with you. Please feel free to send a patient portal message or use our pMD texting application to reschedule as well. Please note, our appointment reminder system may still notify you of your upcoming appointment if it is within the next 3 days. Please ignore that message.

Cancel An Appointment

Cancel An Appointment

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