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Cancellation Policy Form - Peaceful Heart Therapy

Cancellation Policy Form - Peaceful Heart Therapy 2026

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61 votes

The document outlines the No Show/Late Cancellation Policy of Jill Alger-James, LCSW, emphasizing the importance of providing at least 24 hours notice for appointment cancellations to avoid fees. It details the charges for missed appointments and late cancellations, while also stating that fees may be waived in cases of serious illness or emergencies.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the 'Patient Name' field. This ensures that your appointment details are correctly associated with you.
Next, review the cancellation policy carefully. Note the fees associated with late cancellations and no-shows, as this information is crucial for understanding your responsibilities.
Sign the form in the 'Patient Signature' field to acknowledge that you understand and agree to the cancellation policy.
Finally, enter today’s date in the designated 'Date' field to complete your form submission.

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Versions	Form popularity	Fillable & printable
2015	4.6 Satisfied (61 Votes)

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