Clinic Service Termination Request Form
Submit this form to request the termination of a clinic service. The Clinic Service Termination Request Form captures essential administrative details needed to process your request.
Full Name of Requester
*
First Name
Last Name
Relationship to Patient
*
Please Select
Self
Parent or Guardian
Spouse/Partner
Authorized Representative
Other
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Clinic Service or Department to be Terminated
*
Please Select
General Practice
Pediatrics
Dental
Physical Therapy
Laboratory Services
Other
Account or Reference Number (if applicable)
Termination Effective Date
*
-
Month
-
Day
Year
Date
Reason for Service Termination
*
Please Select
Moving to a new provider
No longer need services
Dissatisfied with service
Other
Preferred Follow-Up Method
*
Email
Phone
No follow-up needed
Additional Request Details
Submit Request
Should be Empty: