I understand that I am responsible for the time set aside for service for me or my family members and that a charge will be made for such scheduled appointments if they or I do not keep them, unless 24-hours notice is provided. Insurance companies cannot be billed in such circumstances.
I have read this form and any questions I had have been fully addressed. I understand its contents and agree to its terms.
By checking this box I agree that my typed name will constitute my signature.