Cancellation Policy Form

We understand that illness, emergencies, flat tires, and bad weather do occur. We ask our patients to give us 48 business hours notice whenever possible if they cannot keep an appointment. This allows us time to fill our schedule with other patients who may be waiting.

Policy and Fees

Cancellation or rescheduling of an appointment with 48 hours or more notification – no charge

Cancellation or rescheduling of an appointment with less than 48 hours and up to 24 hours may or may not be considered a broken appointment; it will be at our discretion.

Failure to give 48 hour advance notice

We allow for one (1) broken appointment within a 12 month period

Any additional broken appointments within a 12 month period will be charged a fee of $75 for a hygiene appointment. A fee will also be charged for a broken appointment with the Doctor. The price of a broken appointment fee with the doctor will depend on the length of the scheduled appointment.

Definition of “Broken Appointment”

A broken appointment is any appointment that is canceled or rescheduled with less than 48 business hours' notice OR a scheduled appointment for which the patient does not show up.

Our number one concern is our patient’s dental health. Providing services in a timely manner is critical to accomplish that goal. Our other goal is to keep the cost of dental services as economical as possible. The appointment you schedule for treatment is reserved for you and your treatment only. When you fail to keep your appointment without providing us adequate notice, this adds to the overall cost of care, as trained professionals and dental facilities are not being utilized. We appreciate your understanding and consideration regarding our appointment policy. If you have any questions or concerns, please do not hesitate to ask us at Woodman Dental Care.


All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.