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Please read this portion carefully as it outlines the scheduling and payment policy of Glenn
Fertility & Family Wellness. If you have questions or concerns about this policy, please feel free
to contact us for clarification.

Why this policy exists: This policy ensures quality service and patient convenience at the
clinic. By complying with this policy, you help our patient community enjoy professional,
efficient, effective service.


Appointment cancellations, as a courtesy, should be made within 48 hours. All appointment
cancellations MUST be made by 12pm one business day prior to your scheduled appointment
time. Failure to do so results in the following:
Per Session Rate appointments cancelled after 12pm one business day prior to a
scheduled appointment will be billed at 50% of the appointment fee.
Per Session Rate appointments cancelled the same day of scheduled appointment
will be billed at 100% of the appointment fee.

How we charge for missed per-session appointments: Glenn Fertility & Family Wellness sends
notice via email of the charge. If no email address is on file for the patient, we attempt to
contact the patient via phone to advise of the charge. Whether or not we successfully contact
the patient, the charge is made to the patient’s account on file.


How we collect the fees for missed appointments: Glenn Fertility & Family Wellness uses
reasonable means to collect any missed appointment fees, including contacting the patient
via phone, email or regular U.S. Mail. Additionally, the clinic may use legal means of collecting
a debt to obtain payment for the outstanding charge, such as hiring a collection agency to
collect payment for delinquent accounts.


When we expect payment for missed appointments: Payments for missed appointments are
expected within 30 days of the missed appointment, or at your next visit, whichever comes
first. If not remitted after 30 days, collection action, as outlined in the previous paragraph,
may be initiated.


By obtaining this form, I acknowledge my agreement with all aspects of this policy and I
authorize Glenn Fertility & Family Wellness to bill me if I do not give appropriate cancellation
notice as outlined in this Cancellation Policy.

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