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Refusal Agreement for Card on file
Dentists of Scottsdale strives and dedicates their time to provide the best oral health care and patient-provider relationship at our practice. We are blessed to have a "waiting list" of patients waiting for a dental reservation at our practice.

Therefore, we ask for all patients to contact us (2) business days prior to the patient's dental reservation for any cancellations and/or reschedules.
(Reminder: Holidays do not count as a business day)

Our business hours are shown below:
Monday 8-5pm
Tuesday 8-5pm
Wed 11-5pm
Thursday 8-5pm
Fridays- Closed (unless provided otherwise)

If the patient does not contact Dentists of Scottsdale (2) business days prior to his/her appointment, he/she will be charged $75/hr for cancellation fee and balance will be held on file.

**Patient will be contacted same day to collect same day cancellation fee. If patient is unable to answer, patient AGREES he/she will fulfill balance prior to next appointment since patient has declined our office policy. Patient will need to complete the "outstanding balance" to reserve time with our dental provdiers again and PRIOR to any future reservations***

If you are cancelling due to an illness, a DOCTORS NOTE is REQUIRED within (48-72) hrs to waive the cancellation fee. (or else the system will be automatically charge the card on file)
**NOTE: Home test(s) will NOT be accepted to confirm any patient sicknesses/illnesses. A doctor's note is needed**

If the patient is feeling unwell (multiple) day(s) before the dental reservation, he/she is HIGHLY RECOMMENDED to RESCHEDULE; once he/she receives the (2) day -or-(7) day advanced confirmation reminder via text/email/call prior to appointment.

All patients are sent a text/email/call of the cancellation fee ($75/hr) prior to their appointment and are provided with multiple reminders.

The patient agrees to respect our dental providers time and provide a (2) business day advanced notice, to cancel and/or reschedule their appointment.

If patient fails to do so, patient agrees to the payment of $75.00/hr to be charged to dental account and will be added as a "balance" until paid in full prior to next dental reservation. 
(May has the right to add a card on file later if wanted and will sign a new consent if added)
By signing below, you agree to the terms stated above and have fully read through the agreement and had a chance to ask any questions prior to signing:

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