Missed Appointment and Cancellation Policy

Please note this form must be completed in order to confirm your appointment.

At Pacific Pain and Wellness Group we take great strides to reserve dedicated patient times for appointments. It is for this reason that we collect credit card information ahead of time.
First Name
Last Name
Address 2
Phone Number
Email Address
Please note that your credit card will only be charged if the appointment is missed/canceled less than 48 hours prior to your appointment.
Missed Appointment Fee
Name as on Card
Card Billing Address
Card Billing Zip
Card Number
Card Expiration Date

By entering the information above, I understand if I cancel my new patient appointment less than 48 hours prior to my appointment or no show/miss my appointment, my credit card will be charged $275, the full amount of the appointment. We do not charge the card if an appointment is cancelled 48 hours in advance.
I understand