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Appointment Cancellation Form

For your convenience,  please use this form to cancel an upcoming appointment.  Please provide us with a minimum of 24 hours notice in order to properly cancel your appointment.  Missed appointments or appointments cancelled without 24 hours notice may be charged a $35.00 fee (includes HST) to the patient.

If you need to reschedule your appointment, please call us at 548-483-6275 or you can book a new appointment with your primary care provider by clicking here to submit an appointment request.

Forms Confidentiality & Legal Disclaimer:

The forms on this website submit electronic information via email. The messages sent via email form submission and any of the information and/or files transmitted are confidential and intended solely for the use of the individual or entity to whom they are addressed. Disclosing, copying, distributing, or taking any action in reliance on the contents of this confidential information is strictly prohibited. Internet form submission via email cannot be guaranteed to be secure or error-free, as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. Belmont Medical does not accept liability for any errors or omissions in the contents of the submitted information which may arise as a result of email transmission or internet information protocols. Belmont Medical accepts no liability for the content of this email form submission, or for the consequences of any actions taken on the basis of the information provided.

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