No-Show Fee Appeal Request Form

Request for No-Show Fee Appeal

When a student fails to show up for an appointment, or cancels without adequate notification, other students who could have been served in a timelier manner must wait longer for necessary services.

If you believe that we have made an error in charging you for a no-show/late cancellation, or feel you deserve special consideration for such a fee, please complete the following form.

Appeals must be submitted within 30 days of appointment date.

Today's Date

Student ID

Name

Email Address

Date of services you are appealing

Reason for the appeal request:

Sent email message to cancel.

Date email sent:

Left voice message to cancel.

Voice message left on:

Spoke with someone.

Spoke with:

Date spoke with someone:

Other:

Other/Comments

I understand that the appeal process is not a guarantee of reversal of the no-show/late cancellation fee. After this form is received it will be given consideration and we will provide an email response at the email address listed above.

I certify the information provided is true and correct to the best of my knowledge.