Patient Form

Cancellation & Broken Appointment Policy

Please review and acknowledge our cancellation policy so we can serve all our patients well.

Please do not include emergency medical information in this form. If you are experiencing a life-threatening emergency, call 911.

Select office *

ZIP code

Patient

First name *

Last name *

Acknowledgment

I understand Valley Dental Care requests at least 24-48 hours' notice to change or cancel an appointment. *

I understand repeated missed or late-cancelled appointments may be subject to a fee as permitted by office policy. *

Electronic signature

By typing my name below, I understand and agree that this electronic signature has the same effect as my handwritten signature.

Typed full legal name *

Date

I confirm this is my electronic signature and the information I provided is accurate.

By submitting this form, I understand that Valley Dental Care will use this information to contact me and prepare for my dental visit. See our Privacy Policy and Terms of Use.