Community Outreach

Clinic Appointment Cancellation

To cancel your appointment, please use the form below to cancel at least 24 hours prior to your appointment time. If you are unable to give us 24 hours notice, please do not use this form, but call us at (859) 323-3900.

First name:
Last name:
E-mail:
Date of birth:	(dd/mm/yyyy)
Date of appointment:	Day Month Year
Time of appointment:
Please indicate the healthcare provider(s) you were scheduled to visit:
Physician/Provider: