PATIENT NOTIFICATION OF APPOINTMENT CANCELLATION 
AND NO-SHOW POLICY

Staff will attempt to remind patients one day before their scheduled appointments. This is a courtesy service and does not relieve the patient from their responsibility to arrive for their scheduled appointments. Failure to cancel an appointment within 24 hours is considered a NO-SHOW and the following will apply:

1.	The patient will be expected to cancel an appointment 24 hours in advance by telephoning the physician’s office for notification during regular office hours.
2.	A $40.00 charge will be applied to patient’s account for clinic appointments and $150 for ASC appointments. 
3.	If the patient NO SHOWS; staff will attempt to contact patient to reschedule.
4.	The patient may be terminated from Pain Care Boise after 3 documented no-show appointments within a 12 month period. 
We do understand that emergencies arise and that it may not be possible to give a 24 hour notice. Exceptions to the No-Show/Late Cancellation Policy will be determined by the manager.

Patient Name ______________________________               
Patient Signature ___________________________             Date ___________________