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Discretionary waiver of late cancelation fees
Terms and conditions
Late cancellations and missed appointments represent a significant cost to the practice when other patients could have been seen in the time set aside for the patient.
Failure to provide adequate notice for cancelled, rescheduled, or failed appointments will result in a minimum fee of ยฃ50 per appointment, depending on the duration of the appointment/s cancelled. We completely understand there may be, on occasion, unforeseen circumstances, and we take into account all valid circumstances. For example, if the reason for short notice cancellation (less than 48 hours notice) or non-attendance is ill health or sickness, we might waive or reduce the cancellation fee upon receipt of satisfactory evidence.
If you would like to request a fee discount, please complete this form and attach any supporting evidence.
Please read carefully our
Privacy Policy
ย andย
Terms of Service
.
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Acknowledgement to proceed
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I confirm that I have not previously requested a discretionary waiver of late cancellation fees. I understand that the information on this form will be processed by the management team.
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Patient's details
Name of the patient
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Name of the applicant (if different from the name of the patient)
Relationship to the patient if submitted by a person other than the patient
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Patient's address
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Please enter the full address, including the postcode
Patient email address
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Patient contact number
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Details of the cancelled appointment
Date/ time of the patient appointment
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Date
Time
Name of your dentist at Sunrise Dental Clinic
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Process of the late cancellation
Could you please clarify the process through which you requested the late cancellation?
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Request through a phone call
Request via email
In person request
Request via SMS
Name of the staff member you spoke with regarding the cancellation
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Details of the late cancellation
Reason for the late cancellation
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Sick or feeling unwell
Personal or family emergency
Scheduled another meeting or appointment at the same time
The appointment is no longer relevant or beneficial
Stuck in traffic
Forgot the appointment
Other
Please provide details why you are unable to attend
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Date of sickness
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Have you rescheduled your appointment
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Yes, I have rescheduled my appointment
No, but I will contact the clinic to reschedule
I do not wish to reschedule
Please provide details why you do not wish to reschedule your appointment
*
Please upload evidence
Click or drag a file to this area to upload.
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