In-Person and Tele-Health Appointments Available Same Week Guaranteed
Patient First Name*
Patient Last Name*
Your Email*
Patient Phone Number *
Date of Birth*
1. We require at least 24 hours' notice for any appointment cancellations or reschedules.
2. Cancellations or reschedules made less than 24 hours before the scheduled appointment will result in a $50 late cancellation fee.
3. No-call, no-show appointments will automatically be charged a $50 fee.
4. This fee must be paid before any future appointments can be scheduled or attended.
5. Failure to pay the fee may result in the suspension of services, including prescription refills and follow-up care.
We understand that emergencies happen. Exceptions to this policy will be made on a case-by-case basis at the discretion of IShine Behavioral Health management.
Signature & Date* Today's Date*
By submitting, you agree to receive text messages at the provided number from IShine Behavioral Health. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.