Ithaca Cardiology - Cancel/Reschedule Appointment

Telephone: (607) 272 0460

This form cannot be used if you are cancelling within two business days of your appointment.
Please call us if you need to cancel or reschedule within this time period.

I would like to: Reschedule a Current Appointment Cancel a Current Appointment

Current Appointment Information
The appointment I would like to reschedule/cancel is with: (Name of doctor or other provider)
The appointment is with the following department: (Name of department)
The appointment is for the following date:

Patient Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:


Contact Information
Contact's Name:	(if different from patient)
Day Telephone:
Evening Telephone:
Email Address:
Please contact me by:	to confirm my request.

If you would like to reschedule your appointment, please complete the information below: Time Preference
Day of week:	or
Time of day:
Additional comments:
[additional information]