Skip to main content
Home » No Show Policy Form

No Show Policy Form

We understand that situations may arise in which you will need to cancel or reschedule your appointment. However, each time a patient misses an appointment without providing the proper notice, another patient is prevented from receiving care. Therefore, any patient who fails to arrive for a scheduled appointment without canceling or rescheduling the appointment 24 hours prior to the scheduled appointment time is considered a No Show.

Patients who No Show 3 or more times in a 12 month period will be charged a non-refundable $50 fee. No Show fees are the responsibility of the patient or guardian and must be paid in full before a new appointment will be scheduled.

We appreciate your understanding and cooperation.

Please sign below to acknowledge that you have read and understand the Accurate Family Vision patient No Show policy.
Print Patient Name:
MM slash DD slash YYYY