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Cancellation & No-Show Policy template

A free cancellation and no-show policy template patients can read and sign online. Set your notice period and fees, then collect agreement before the first visit.

Cancellation & No-Show Policy

Our cancellation policy

We hold each appointment time just for you. When a visit is missed without notice, another patient loses the chance to be seen. <ul><li><strong>24-hour notice:</strong> Please cancel or reschedule at least 24 hours before your appointment.</li><li><strong>Late cancellation:</strong> Cancellations with less than 24 hours' notice may be charged a $[XX] fee.</li><li><strong>No-show:</strong> Missed appointments without notice may be charged the full visit fee.</li><li><strong>Late arrival:</strong> If you arrive more than 15 minutes late, we may need to shorten or reschedule your visit.</li></ul> We understand emergencies happen. Fees may be waived at the practice's discretion.

How to cancel

Call or text [Phone Number], or reply to your appointment reminder.

I have read and agree to the cancellation and no-show policy *

I understand that late cancellation and no-show fees are not billed to insurance *

How would you like appointment reminders? *

Signature

Patient full name *

Signature — type your full legal name *

Date signed *

6 things your cancellation policy should say

  1. How much notice you need
  2. The late cancellation fee
  3. The no-show fee
  4. What counts as a late arrival
  5. How to cancel
  6. When fees may be waived
What's included
  • I have read and agree to the cancellation and no-show policy
  • I understand that late cancellation and no-show fees are not billed to insurance
  • How would you like appointment reminders?
  • Patient full name
  • Signature — type your full legal name
  • Date signed
Prefer paper? Print it

Download this form as a PDF or Word file — free, no account. When you're ready, send the same form as a link so nobody retypes a clipboard.

This template is a starting point, not legal or medical advice, and using it does not by itself make your practice HIPAA compliant. To collect patient health information on TendForm, use the HIPAA plan with a signed Business Associate Agreement, and have your own counsel review consent and policy wording.