Payment & Forms


Click on the links below to view and/or save these form files in PDF format. Fill out the forms and email to or fax to (720) 606-4221.


All patients:

Pediatric patients:

Adult patients:


To submit payment for a deposit, please select either Adult or Pediatric deposit below. The full total depends on the length of surgery being performed and can be confirmed after the appointment. Please contact our office for an estimate. The nonrefundable deposit of $300 for children and $500 for adults will serve to secure your appointment. Once the deposit is received, your appointment will be confirmed. Full payment is required on the day of surgery. We accept all major credit cards.

If you would like to pay using CareCredit’s six-month term, please call our office at (720) 606-4220, since this transaction must be managed by phone.

Adult anesthesia deposit – $500.00

Pediatric anesthesia deposit – $300.00


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