(Date)

(Patient Name) (Patient Address)

Dear (Patient Name),

You have (canceled or did not show) for your follow-up appointment on (indicate date) without rescheduling. We have tried multiple times to reschedule your missed appointment. To date, you have not responded to our efforts. Since we have not heard from you, we can only conclude that you have terminated your care with our practice.

Continued care is essential to your health, and failure to adhere to the agreed upon plan of care may have significant consequences. (If the patient has a condition that requires specific care, states the care as well as the consequences of not following up in clear layman’s terms.  If the patient has a condition that needs periodic follow-up, state the frequency and urgency of the follow-up, and state the consequences of not getting the follow-up at the recommended time interval in clear, patient-friendly language.)

I find it necessary to inform you that if we do not hear from you by (date at least 30 days from date of letter) I will no longer be able to serve as your physician. I recommend that you promptly find another physician to provide for your medical needs (state needs if continual medical attention is necessary, e.g., periodontal treatment to clear active infection). Delays could jeopardize your health, so I urge you to act promptly.

I will remain available to provide medical services to you, on an emergency basis only, until (same date as specified in paragraph 3 above) while you have the opportunity to arrange for another oral physician to assume your care. A medical records release authorization form is needed so if you are not returning for care please notify our office with the name and address of your new oral physician. Upon receipt of your signed authorization, I will forward a copy of your medical record. I will also be happy to discuss your medical condition(s) with the physician who assumes your care.

Very truly yours,

(Typed Physician Name)

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Reducing Risk

SAMPLE MISSED APPOINTMENT LETTER

(Date)

(Patient Name) (Patient Address)

Dear (Patient Name),

You have (canceled or did not show) for your follow-up appointment on (indicate date) without rescheduling. We were unable to reach you by telephone.

Continued care is essential to your health, and failure to adhere to the agreed upon plan of care may have significant consequences. It is important to your health that you schedule an appointment within the next (indicate the number of days/weeks/months). You will recall we discussed your need for a follow-up appointment in my office on (indicate the date of last visit or discussion). (If the patient has a condition that requires specific care, states the care as well as the consequences of not following up in clear layman’s terms. If the patient has a condition that needs periodic follow-up, state the frequency and urgency of the follow-up, and state the consequences of not getting the follow-up at the recommended time interval in clear, patient-friendly language.)

Delays could jeopardize your health, so I urge you to act promptly and contact our office as soon as possible to reschedule.

Very truly yours,

(Typed Physician Name)

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