I try to keep in mind what is going on with my patients. Some of my patients have parents who are depressed or ADHD, or are so themselves. Those are the folks I try to give more leeway to. I have myself been in periods where I have been so disorganized that I cold not keep appointments outside of the regular schedule to save my life. literally. I was hugely aware of the inconvenience it caused and felt horrible about it, but it was a problem beyond courtesy at that point. Now my mds work better it is seldom a problem, but I am very much in favor of an SMS reminder system that they are talking about at my work place. It might well be different in the regular med system, but to put that typeof three strikes and you're out system in where I work would penalize the exact same people we are trying to help for the stuff we are trying to help them with. Not cool when it is related to symptoms they can't control, understandable if it is a simple blow-off.