A non-refundable deposit of $200 is required to hold the appointment. This will go toward the final anesthesia fee.
For more information on payment and fees, please see the Financial Agreement below.
Click link below, or call our office at 801-631-1312 to pay your deposit.
Below, you will find the following documents:
Financial Agreement & Insurance Information - A deposit is required in order to schedule appointment.
Medical History Questionnaire - Fill out and fax/email to Summit Anesthesia at time of deposit.
Pediatrician/Primary Care Physician Medical Evaluation - We may ask that you see your doctor between 2 and 5 days prior to your appointment and request that they fax/email us the evaluation. We also request that you bring the original with you on the day of treatment.
Pre-Operative Instructions - Follow these instructions closely to ensure the safest treatment possible.
Post-Operative Instructions - What to expect and what to avoid following your anesthesia treatment.
Anesthesia Consent - Review prior to scheduled appointment. Consent will be signed on day of treatment.
Please download and complete the required documents and return to
or faxing them to (855) 224-0040, unless noted otherwise.