Ultimate Physical Therapy Patient Information Form Page 3

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ULTIMATE PHYSICAL THERAPY ATTENDANCE POLICY
(Please read thoroughly)
ULTIMATE PHYSICAL THERAPY aims to provide each patient with the highest
level of care while attempting to accommodate each patient’s schedule.
Appointments are made to insure you receive the essential one on one time
with your therapist and consistent attendance is essential to your full
recovery.
While we are sensitive to the fact that an emergency may occur, cancellations,
especially last minute ones, along with not showing to an appointment,
decrease our ability to accommodate the scheduling needs of the other
patients.
We must ask for your
full cooperation
with the following policy:
A scheduled appointment
must be cancelled at least 24 hours in advance
or
a fee will be charged for that appointment. 
Failure to show up for an appointment (“NO SHOW”) without notifying us
will result in a fee of $50 being charged for that appointment.
No cancellation fee will be charged if the missed appointment is made up
within the same week it was scheduled and on a day that you do not have
another appointment scheduled. 
All cancellations and no shows will be documented in your medical record
and appropriately reported to your physician. 
Signature:__________________________________________Date_________

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