4845 N. Milwaukee Ave. Chicago, IL 60630 773-647-1093 www.brightersmilechicago.comCancellation Policy: Once a dental appointment has been made, please keep in mind that this time has been reserved especially for you. We require a full 24-hour notice (business hours) for any appointment changes or cancellations-including failed appointments. We reserve the right to charge $75.00 for hygiene related appointments and $150.00 for restorative related appointments without 24 “business” hours including failed appointments.Brighter Smile requires a credit card on file to secure your reserved dental appointment. Visa Master Card Amex Discover Other Please specify:* Card number* Expiration date* MM slash DD slash YYYY CVV* (3 digit verification #) / (Amex 4 digit # front) *Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled. By signing this notice of cancellation policy, I am acknowledging that the policy has been read in its entirety. I also understand that payment of this account is my full responsibility.SignaturePatient / Parent / Guardian SignatureDate MM slash DD slash YYYY
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