DANIEL CASTRO, DDS
                   965 NORTH RESLER, SUITE 105 
                      EL PASO, TEXAS 79912 
                         (915) 532-4929


                


		   FAILED APPOINTMENT POLICY

       IT IS OUR OFFICE POLICY THAT A 48 HOUR CANCELLATION NOTICE BE 
       GIVEN FOR ANY DENTAL APPOINTMENT THAT A PATIENT IS UNABLE TO 
       KEEP. WE RESERVE TIME, SPECIAL, FOR EACH PATIENT. IF YOU FAIL AN 
       APPOINTMENT OR ARE ROUTINELY LATE YOU MAY BE DISMISSED FROM 
       OUR DENTAL PRACTICE. AN APPOINTMENT IS CONSIDERED FAILED 
       WHEN WE DO NOT RECEIVE A 48-HOUR NOTICE AND THERE IS A $25 
       CHARGE WHEN RESCHEDULING OR CANCELLING YOUR
       APPOINTMENT.




       SIGNATURE OF PATIENT OR GUARDIAN   DATE





        ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

       I have read this office's Notice of Privacy Practices attached to clip board.



       Date

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                             Signature


                         For Our Office Use Only

       Our office atternpted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but 
       acknowledgement could not be obtained for the following reason:
         Patient refused to sign
         Communication barriers prohibited obtaining the acknowledgement
         An emergency situation prevented us from obtaining acknowledgement
         Other (Describe below)