SHAC

No Show / Late Cancel Petition Form

Student Health & Counseling (SHAC) receives funding from the Student Fee Review Board which expects that student fees will be used responsibly. When a student fails to keep an appointment or cancels at the last minute, professional time goes unused and other UNM students fail to get timely service.

If we have made an error in scheduling you or you believe you deserve special consideration for a “no show” or “late cancellation” fee, please complete the following information. Your request will be reviewed and we will mail you the decision.

NOTE: The following information will be sent via unencrypted e-mail. If you prefer, you can print the No Show / Late Cancel Petition form (.pdf) and mail it to SHAC, or come into SHAC to pick up a form. For more information, call 277-3136.

 


Name: 

Today's Date:

Address:

City:

State: Zip:

Date of Birth:

E-mail address:

Telephone:

Date Appointment was missed or late canceled:

Time Appointment was missed or late canceled:

Name of Provider you were to see:

Describe SHAC error or the reason for the Special Consideration: