Charlie Crist Ana M. Viamonte Ros, M.D., M.P.H.
Governor State Surgeon General
APPOINTMENT AGREEMENT FORM
In order to work in a timely manner and provide quality dental care to patients who need and desire
treatment, Lafayette County Health Department-Dental Clinic will enforce the following policies:
• If you are 10 minutes late for your schedulable appointment, we reserve the right cancel your
appointment and reschedule you on another day.
• If you miss 3 (three) scheduled appointments without 24 hour notice or without any notice we
will cancel all future appointments and you will lose the right to schedule an appointment in
our clinic for a period of six months. During this period you will only be seen for emergencies.
After six months, you will be able to make one appointment at a time. If you miss one of these
appointments with out 24 hours or more cancellation notice, you will be seen in our clinic for
By signing below, you acknowledge that you have read, understand and agree to the above policy.
Patient or Parent/Guardian Signature Date
Lafayette County Health Department
140 SW Virginia Circle
P. O. Box 1806
Mayo, Florida 32066