This form is to notify Lindsey Dentistry PLLC and its staff of YOUR REQUEST TO CANCEL ALL FUTURE DENTAL APPOINTMENTS which may or may not be scheduled already. This form may be used in regard to notification of a network participation change with my insurance carrier, along with any other reasons.
Please include all Names and Dates of Birth for all members of your family or household in which you wish to cancel appointments for.
Please ensure you have appropriate authority to cancel on behalf of other patients of Lindsey Dentistry PLLC.