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(503) 928-5903
511 SW 10th Ave Suite 1101 Portland, OR 97205
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511 SW 10th Ave, Suite 1101
Portland, OR 97205

Appointment Commitment Agreement

We respectfully request a 2-business day notice for cancellations or rescheduling an appointment. This allows enough time to contact our patients waiting for treatment.


If you are unable to allow a 2-business day notice, we will notate the account with a Short Notice Cancellation warning. If any additional Short Notice Cancellations occur, we will apply a Cancellation fee to the account. This fee is $75 for Hygiene hour and $150 for a Doctor hour.


We are 100% committed to our patients and respectfully request the same in return.


Electronic Signature

Patient First Name: *

Patient Last Name: *

Date: *

The person filing out form is: *

If Representative, Representative';s Name:


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Request Your Samuel Seo, DMD
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Samuel Seo, DMD

PDX Center for Dentistry

(503) 928-5903
Portland OR 97205

PDX Center for Dentistry | | (503) 928-5903
511 SW 10th Ave, Suite 1101, Portland, OR 97205
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