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Click the orange button to download the form.

FILL OUT THIS FORM AND MAIL TO Port Orange Gynecology in Port Orange, Or FAX to 888.987.7157

Patient Bill of Rights


We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family.  However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment.  Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly "full" appointment book.  If an appointment is not cancelled at least 24 hours in advance you will be charged a seventy five dollar ($75.00) fee; this will not be covered by your insurance company.

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