Request Appointment Cancellation

Disclaimer

By providing my phone number to Dermatology Consultants, I agree and acknowledge that Dermatology Consultants may send text messages to my wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP”. For more information on how your data will be handled please see the Privacy Policy below.

Privacy Policy

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

Patient Name *

First

Last

Patient Birth Date *

Phone Number *

Email (For referring clinic coordinators, please provide the referring clinic email address) *

Appointment Date *

Physician

Additional Information (Do not send medical questions.)

Do you want to be contacted by phone to reschedule your appointment? *

Attention Cosmetic Patients:

Fraxel & Ulthera appointments cancelled and not rescheduled within 72 hours of the appointment will be charged a 15% service fee.
Sculptra appointments cancelled and not rescheduled seven days prior to the appointment will be charged a 100% service fee.
All other cosmetic appointments cancelled and not rescheduled within 24 hours of the appointment will be charged a $50 service fee.

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Request Appointment Cancellation

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