Notice of Missed Appointment #2 (1)

Signed Date

Date

OoLi Orthodontics Location

OoLi Orthodontist Name

Patient Name

Address

Patient Email

Patient Phone

Patient / Parent / Guardian Name

Patient / Parent / Guardian Email

Patient / Parent / Guardian Phone

It has been brought to attention of OoLi Orthodontics that above patient has failed to show up for orthodontic appointments again. Orthodontic treatment may be terminated if this pattern continues. Any future missed appointments may result in removal of the braces and immediate dismissal from orthodontic treatment. We require that patients remember their scheduled appointments to ensure completion of the orthodontic treatment planned for that day.

Missed or late appointments prolong orthodontic treatment and may potentially contribute to dental health problems. These problems include loss of tooth enamel, increased risk of cavities and gum disease, and the possibility of injury to the mouth from loose or broken appliances.

Please contact Dr. Park at OoLi Orthodontics as soon as possible to schedule an appointment. If you are no longer interested in receiving orthodontic treatment at OoLi Orthodontics, kindly provide us with a written request to forward your records to another orthodontist. If you have decided that you do not wish to continue with orthodontic treatment at all, we recommend that you make an appointment to have the orthodontic appliances removed.

Sincerely,

W.W. Jonathan Park, DMD, MS

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

Timestamp

Audit

May 1, 2022 12:24 am MST

Notice of Missed Appointment #2 (1) Uploaded by Won-Woo Jonathan Park - forms@ooliortho.com IP 70.163.243.141

January 15, 2023 8:16 pm MST

OoLi Forms - froms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

January 15, 2023 8:16 pm MST

WW Jonathan Park - drpark@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

January 15, 2023 8:27 pm MST

OoLi Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

January 15, 2023 8:27 pm MST

WW Jonathan Park - drpark@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

April 16, 2023 12:11 am MST

OoLi Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

We're not around right now. But you can send us an email and we'll get back to you, asap.

Start typing and press Enter to search