I, _________________________________, have been scheduled for a procedure with John J. Basile, M.D., or Sunil V. Patel, M.D. I understand that an advance notice of 48 hours is required for cancellation in order to avoid assessment of a $100.00 fee. I agree to pay this fee, and understand that it is not the responsibility of my insurance company.


Signature: ___________________________________


Date: ___________________________________


Witness: ___________________________________