healthy kids care

Cancellation / Rescheduling / No-Show Fee Policy

We respectfully request that parents or guardians notify our office in advance if an appointment needs to be canceled or rescheduled. If a patient fails to attend a scheduled appointment (no-show) or the office is not notified 24 hours prior to the appointment time, a $25.00 missed appointment fee is applied.

If a parent or guardian states they contacted the office to cancel or reschedule, proof of the call or communication may be requested. If the office is unable to verify the cancellation or rescheduling, the $25.00 fee will remain the responsibility of the parent/guardian.

***The appointment fee will be due at the patient’s next scheduled visit.***

Forms & Administrative Fees

Forms such as sports physicals, school forms, FMLA paperwork, and newborn screening documentation must be presented at the time of the appointment. Form fees, ranging from $25–$60, are due at the time of service. Requests submitted after the appointment will still incur a form fee and may require the patient to schedule a return visit, depending on the date of the most recent annual wellness exam (typically within the last 6 months), as determined by the provider.

Patient Financial Responsibility & Insurance Billing Policy

As a courtesy, our office will submit claims to your insurance carrier for services rendered. However, insurance coverage is a contract between you and your insurance company. Payment from your insurance company is not guaranteed, and coverage may vary depending on your specific plan benefits.

acknowledge that I am financially responsible for any charges not covered or paid by my insurance, including but not limited to deductibles, copayments, coinsurance, and non-covered services.

If my insurance company does not pay the claim within a reasonable time or denies payment, the remaining balance will become the responsibility of the patient or guarantor.

By signing this form, I acknowledge and agree to the following:

1. Age Requirement
   I confirm that I am 18 years of age or older. If the patient receiving the ear piercing is a minor, a parent or legal guardian must sign this consent form.
2. Health Status
   I confirm that the patient does not have any known medical condition or is taking any medication that would make ear piercing unsafe, including conditions that may affect healing or increase the risk of infection.
3. Possible Risks
   I understand that although proper sterile techniques are used, possible risks may include infection, irritation, allergic reaction to metal, or scarring.
4. Procedure Information
   I understand that the ears will be pierced using sterile, medical-grade stainless steel piercing studs and equipment.
5. Aftercare Responsibility
   I agree to follow the aftercare instructions provided by Healthy Kids Care for the recommended period to help reduce the risk of infection or complications.
6. Release of Liability
   By signing below, I release and hold harmless Healthy Kids Care (HKC), its providers, employees, and affiliated staff from any claims, damages, or liabilities that may arise from the ear piercing procedure performed at my request, except in cases of gross negligence.