Patient Paperwork No Show Policy Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. policy missed DATE We are honored that you have chosen to obtain your care with Penn-Tampa Neurology, however, if you miss a scheduled visit, that compromises your care. In addition, it compromises the care of patients who might have wanted to be seen during that time slot. Please provide us with 24-hour notice for cancellations. 1st event: we will call to reschedule you. You will be charged a $35 fee 2nd event: we will call to reschedule you. You will be charged a $35 fee 3rd event: you may be discharged from the practice. You will be charged a $35 fee Regarding diagnostic testing: when we schedule patients for diagnostic testing, we schedule the physician, reserve equipment, and often schedule a technologist. This is similar to what is involved with scheduling surgery. A no-show for diagnostic testing will be charged $50, and unless there are extenuating circumstances, testing may not be rescheduled. Our main concern is to provide you and the other patients in our practice with the best neurology care possible. I understand the missed appointments policy *SIGNATURE Clear Signature DATESubmit No Show Policy Form