Pure Dermatology
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Look like your BEST self and have PURE Confidence with Pure Dermatology!

Pure Dermatology strives to see all patients in a timely and efficient matter. As a courtesy, we attempt to contact each patient 24 to 48 hours prior to their scheduled appointment to remind them of the date and time. However, it is the responsibility of the patient to arrive on time for their appointment or join any televisit video appointments at the scheduled time. Failure to show for an in-office or televisit appointment are considered a missed appointment. Your time is valuable, as is ours, and if you are unable to keep your reservation, we request that you give our office a minimum of 24 HOURS notice, should you need to cancel or reschedule an appointment. Appointments cancelled within 24 hours will be considered a missed appointment, as well. Failure to comply with this policy will result in a missed appointment fee, which is NOT covered by insurance. The missed appointment fees are as follows:

Thank you for understanding our policy to assist in the most efficient care for all our patients.

I have read and understand the cancellation policy of Pure Dermatology, and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice.

Patient Name:__________________________________________________________________________________

Parent/Guardian (if patient under 18):_________________________________________________________________

Signature:_________________________________________________________ Date:_______________________