Appointment Commitment Agreement

We respectfully request 48 hours advance notice for canceling or rescheduling an appointment. This allows enough time to contact our patients waiting for treatment.


If you are unable to allow 48 hours notice, our policy provides that you will receive a written notice reminding you of our Appointment Commitment Agreement. If a second occurrence happens within a 12 month time period, we will ask that all future appointments be paid in full 1 week prior to a scheduled appointment.


If you should miss the prepaid appointment, there will not be a refund of prepaid funds and all future appointments will need to be paid ahead of time. We are 100% committed to our patients and respectfully request the same in return.


Electronic Signature

Patient';s First Name: *

Patient';s Last Name: *

Date: *

The person filing out form is: *

If Representative, Representative';s Name:


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As a patient, three things stand out to me about Cooley Smiles - the great quality dental work, the cleanliness of the facility and thorough follow up. These are major differentiators that I look for in dental providers and to-date, I've always been satisfied with my experience. Thanks for the great patient care, Cooley Smiles team!

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Cooley Smiles -
18031 67th Avenue NE, Kenmore, WA 98028-4839
- (425) 216-3367

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