Please fill out and sign this form. If you prefer to print a copy of this form to fill out by hand, you may do so by downloading the PDF version
. Please bring it with you to your appointment or mail it in ahead of time.
Waterville Community Dental Center
Dear Valued Patient:
We are a non-profit dental center and are able to continue to provide dental care services in part from the generosity of the United Way, grants from private foundations and donations from caring citizens.
One broken appointment affects the…
- person who breaks the appointment and misses out on dental care,
- person who needs an appointment and has to wait to get one,
- dental staff who care about your dental health, and
- Waterville Community Dental Center who loses money because they are unable to fill the empty space in the schedule.
BROKEN APPOINTMENT POLICY
An appointment is considered to be broken if any of the following occur:
- The patient fails to appear for the appointment,
- The patient arrives more than 15 minutes late for a scheduled appointment, or
- The patient cancels or reschedules with less than a 48-hour notice.
Two broken appointments within a year results in the patient and all family members being transferred to the ‘same day appointment’ list. If you are put on this list, you will not be allowed to schedule an appointment in advance and will need to call the day of and we will fit you in if there is a place in the schedule available.
Same day appointment broken appointment will regrettably result in you and your family members being dismissed from our dental center.
We understand plans change and to be sure that you do not incur a broken appointment, please notify our office at least 48 hours in advance of the appointed time.