No Show/ Cancellation Policy

Purpose: The Dr’s and Staff at Desert Lake Family Dentistry respects your time and we ask the same courtesy. Missed appointments/no-shows affects our ability to provide timely attention to our patients. When a patient does not show up for
their appointment, another patient loses an opportunity to be seen. If you are unable to make your appointment, we respectfully ask that you notify our office 24 hours in advance. Failure to cancel an appointment with a 24 hour advance
notice from the scheduled appointment time will be considered a no-show and you will be charged.

 If a confirmation call was documented and the patient fails to appear for his/her appointment, a no-show will be documented in the patient’s chart. You will be billed as follows:

  • Exam= $40
  • Treatment appointment= $40 per hour
  • Oral Sedation= $160

After 2 no-shows, you will be put on walk-in basis only.

I have read the above and understand Desert Lake Family Dentistry’s policy. I will do everything I can to assure that when I have confirmed an appointment, I will arrive on that specific day and time. I also understand that there may be
extenuating circumstances that arise in which I have to make a last minute cancellation, we at Desert Lake Family Dentistry understand this when situations arise and will try to be accommodating with rescheduling. IT IS ABSOLUTELY NECESSARY THAT YOU CALL OR RETURN TEXT AND CONFIRM ALL APPOINTMENTS OR YOUR APPOINTMENT WILL BE CANCELLED.


I certify the truth of all information given. I also authorize the release of pertinent information to those parties requiring it for the treatment or for the purpose of payment of the account or credit reference. I authorize payment of insurance
benefits directly to Desert Lake Family Dentistry, Dr. Adel Shayegan DDS. I understand that my dental insurance carrier may pay less than the actual bill or services. I understand I am financially responsible for payment of services not paid, in whole or in part, by my dental care payor.

Patient Name:(Required)
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