This agreement is between Three Village Neurology and the patient, who has agreed to schedule an appointment at the practice.

Non-Refundable Deposit: In the event that the patient does not show up for the scheduled appointment, a non-refundable deposit of $150 will be charged to the patient.

Appointment Cancellation: The patient may cancel the appointment by contacting Three Village Neurology at least 48 hours prior to the scheduled appointment time.

Payment Responsibility: The patient is responsible for paying all fees associated with the appointment, including the non-refundable deposit if they do not show up for the appointment as scheduled.

Agreement to Terms: By scheduling an appointment with Three Village Neurology, the patient agrees to the terms of this agreement.

This agreement is binding and enforceable under the laws of New York state.
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