RD - MISSED VISIT

DISCIPLINE
PATIENT NAME PATIENT NAME First Last
PATIENT DOB PATIENT DOB / MM / DD YYYY
DATE OF SCHEDULED APPOINTMENT DATE OF SCHEDULED APPOINTMENT / MM / DD YYYY
SOURCE OF PAYMENT
TYPE OF MISSED VISIT

TYPE OF MISSED VISIT TREATMENT EVALUATION RE-EVALUATION
REASON FOR MISSED VISIT

REASON FOR MISSED VISIT Patient is sick Patient has an appointment conflict Other Other
PLAN
TERMS OF ACCEPTANCE and SIGNATURE
ELECTRONIC SIGNATURE
By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature.

Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
THERAPIST & NPI
I UNDERSTAND THAT CHECKING THIS BOX CONSTITUTES A LEGAL SIGNATURE CONFIRMING THAT I ACKNOWLEDGE AND AGREE TO THE ABOVE TERMS OF ACCEPTANCE.
Date Signed Date Signed / MM / DD YYYY