Intake Form

No Show / Late Cancellation Policy

 

We at REVIVE Center for Health and Wellness understand that you may need to cancel an appointment occasionally. In such circumstances, please contact us no later than 24 hours before your scheduled appointment time. You may do so by calling 860-375-2227 or by using the patient portal. Please review our financial policy.

If you do not show up for your appointment or cancel or reschedule within 24 hours of your appointment time, we will consider that a no-show.

No-show appointments for any office visitwill be subject to a $50 fee. Any No-

Show appointment for a Physical visit will be subject to a $100 fee.

No-show fees are the patient’s sole responsibility and must be paid in full before your next appointment. If the no-show fee might prevent you from receiving necessary care, please contact us.

We know that unexpected situations sometimes arise. In the case of emergencies or extenuating circumstances, we may waive the no-show fee. Waivers are determined on a case-by-case basis at the practice management's sole discretion.

If you have questions about our cancellation policy, or you’re experiencing an emergency, please call 860-375-2227 or email the practice manager at revivehealthct.com@gmail.com.


Patient Name:

Date:

Lab & Imaging Results Policy


Nurse Practitioner Jennifer Jerome has direct access to lab results through the following places:

  • 1. Quest Diagnostics
  • 2. Lab Corp

Please note that if a patient chooses to use any other lab facility for their bloodwork it is the patient’s responsibility to receive the lab results and/or have them faxed over to the office.


The office has direct Imaging result Access from:

  • 1. Jefferson Radiology
  • 2. Vernon Imaging
  • 3. Radiology Associates of Hartford

Please note that if a patient chooses to use any other imaging facility it is the patient’s responsibility to call and request that their imaging results be faxed to the office at 860-603-5080.

Patient Name:

Date:

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