WP E-Signature by Approve Me - Sign Documents Using WordPress -

Appointment Cancellation Policy/ No Show Policy

1. Cancellation Policy/ No Show Policy

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you are preventing another person from getting treatment.

Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly "full" appointment schedule.

If an appointment is not canceled at least 24 hours in advance, you will be charged a fifty dollar ($50) fee.

2. Scheduled Appointments

We understand that delays can happen due to a variety of issues, however we must try to keep other patients on time. If a patient is 15 minutes past their scheduled appointment, we may have to reschedule the appointment.

3. No-Call Cancel/ No Show for more than two "2" appointments may result in dismissal from program with no refund.

I acknowledge that I have read, understand, and agree to abide by the Cancellation/ No Show Policy.

Patient Name: {{patient_first_name}} {{patient_last_name}} Date: {{current_date}}

Birthdate: {{patient_birthdate}}

Member Signature:

Witness Signature:

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., CO., Primary Medical of IN, P.C.
2025.07.09

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Alex AssessmentTest
(Awaiting Signature)

(Awaiting Signature)

Michelle Clark
(Awaiting Signature)

Ted Ennenbach
(Awaiting Signature)

Lynn Scott
(Awaiting Signature)

EnnuLife Patient Docs
(Awaiting Signature)

Signature Certificate

Appointment Cancellation Policy

Unique Document ID: 790b5bd3e138ec48c521758756dacba66d5f5709

Build. Track. Sign Contracts.

EnnuLife Patient Docs

Party ID: 912778d3-c6da-470f-8c3c-b93a78d14947

Awaiting signature

Lynn Scott

Party ID: 9b317c7c-cb4c-47e2-b751-d35f95204d2d

Awaiting signature

Ted Ennenbach

Party ID: 53ef3992-70b1-4f77-87d7-c48bb41977d1

Awaiting signature

Michelle Clark

Party ID: 11dd3bef-afec-4606-b3c4-4f5bcddac8b2

Awaiting signature

Party ID: f77b9040-fd92-435e-b963-8872205d5f9e

Awaiting signature

Alex AssessmentTest

Party ID: 6673d599-4b58-4710-8a47-9f5cb69caf4e

Awaiting signature

Timestamp

Audit

2026-03-03 09:12:15 UTC

Document Appointment Cancellation Policy
Uploaded by EnnuLife - docs-admin-ennulife@ennulife.com
IP: 0.0.0.0

2026-03-05 14:23:07 UTC

Document viewed by EnnuLife Patient Docs - docs-admin-ennulife@ennulife.com IP 24.238.5.27