THE FORT CHRISTIAN PSYCHIATRIC CENTER
about The Fort Christian Psychiatric Center
About Dr. Fortuchang
This cancellation form is for patients only.
*
Indicates required field
Your Name (*Parents: include full name of child)
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First
Last
[object Object]
Your Email Address
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Your Phone Number
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Full Date of Appointment Being Canceled
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Time of Appointment Being Canceled
*
Sections 1a & 1b are only for CURRENT PATIENTS. Parties with a pending diagnostic evaluation should check NOT APPLICABLE.
1a. Check the applicable box:
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I am canceling MY appointment.
I am canceling MY CHILD'S appointment.
1b. I acknowledge that it is my responsibility to call the office & reschedule in a timely manner. Check the applicable box:
*
Understood & acknowledged. I WILL reschedule.
Understood & acknowledged. I WILL NOT reschedule. I understand that by choosing NOT to reschedule I am requesting to TERMINATE SERVICES. Thank you.
Submit
about The Fort Christian Psychiatric Center
About Dr. Fortuchang