Wayne Neurology<br/>34815 W Michigan Ave. Wayne, MI 48184 Tel: 734-721-4739 Fax: 734-725-3184 Text: 734-494-0638<br/> <br/>Cancellation and No-Show Policy<br/> Dear Patient:<br/>We strive to meet and exceed the expectations of all our patients, and we are dedicated to rendering excellent medical care to you all. In order to meet your needs, we are implementing a cancellation and no-show policy. This policy enables us to better utilize available appointments for our patients.<br/>We understand that situations arise in which you must cancel your appointment. It is therefore requested that if you must cancel your appointment you provide at a minimum 48 hours? notice.<br/>Time is specifically reserved for you on the physician?s schedule when you make your appointment. When sufficient notice is not given to cancel or reschedule your appointment, it does not give us enough time to contact another patient who could come to the clinic during your assigned time. This results in patients not getting the care they need when they need it.<br/>As a courtesy, we contact you, multiples time prior to your appointment to remind you of your appointment.<br/>Office appointments which are cancelled with less than 48 hours prior notice may be subject to a $50.00 cancellation fee. Cancellation of less than 48 hours will be reviewed on a case-by-case basis.<br/>Patients who do not show up for their appointment without a call to cancel an office appointment will be considered a NO SHOW. Patients who no-show three (3) or more times in a 12-month period may be dismissed from the practice and denied any future appointments. Patients may also be subject to a $50.00 fee for not showing up to an appointment.<br/>NOTE: THESE FEES ARE NOT COVERED BY YOUR INSURANCE COMPANY AND ARE THE SOLE RESPONSIBILITY OF THE PATIENT AND MUST BE PAID IN FULL BEFORE THE NEXT APPOINTMENT.<br/>Our practice firmly believes that good physician/patient relationships are based upon understanding and good communication. Your health is important to us.<br/>Please sign that you have read and understand this Cancellation and No-Show Policy <br/>__________________ ______________________ Patient Name (Please Print) Date of Birth<br/> <br/>__________________ _______________________ Signature of Patient or Representative
