Appointment Cancellation

Please use this form to request an appointment cancellation. Please note that all cancellation requests require 24-hours notice. Any cancellation received within 24-hours of the scheduled appointment will be subject to any applicable cancellation fees.

PATIENT INFORMATION

First Name

Last Name

Patient Date of Birth

YYYY

PARENT/GUARDIAN INFORMATION

First Name

Last Name

Parent Email

Parent Phone

(###)

###

####

Cancellation Reason

Please tell us why you are cancelling this appointment. If cancelling due to sickness or doctor visit, we will follow up to request a copy for our records.

Service Type(s) Being Cancelled

Date of Appointment

Please tell us the date of the appointment you are requesting to cancel.

YYYY

Time of Appointment

Please tell us the time of the appointment you are requesting to cancel.

Hour

Minute

Second

If available, would you like to convert your appointment to virtual (online/video) to maintain your child's progress in therapy?

Yes