cancelation fee glib not provide the re:It:red notice of cancelabon. or if I do not keep my aPcontment and have not canceled. I have been provided the Faculty Group Practice Patient Financial Policies. I understand the Information listed above which has bean fully explained to me. Wit Signature I I - Guarantor Signatu

celation fee if I do not provide the required notice of cancelation, or if I do not keep my appointment and have not canceled. I have been provided the Faculty Group Practice Patient Financial Policies. I understand the information listed above which has been fully explained to me. Patient Signature uate uarentor Signa