(2022) Surgery Deposit Form​


Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Fax: 623.471.5180


We want to help our patients fully understand their financial obligations when scheduling surgery at our practice, along with our payment and cancellation policies prior to undergoing surgery with Dr. Becker. When you schedule your surgery, we must secure a time in the operating room at the surgery center as well as with our Anesthesia group. Both the facility and our Anesthesia group hold Dr. Becker accountable if this time is not used. Furthermore, we must turn down every other patient who wants surgery on the day and time we have reserved on your behalf. The Surgical Deposit & Payment Policy Agreement is outlined below. When you feel you understand the contents of this form and agree to the terms, please sign and date on the line indicated below.


I understand that once my surgery is scheduled with Dr. Becker and the operating room is reserved at a specific time for me, it is no longer available to other patients. Therefore, I agree to submit a $1000 surgical deposit at the time I request my surgery to be scheduled. The operating room and anesthesia fees are all included in your total cost to Dr. Becker. Pathology testing (if requested) is a bill that is not included in surgery cost. Any remaining balance for your surgery must be paid in full at two weeks (14 days) prior to the date of your surgery, which can be split into a maximum of three (3) payments, excluding cash payments and the initial payment of your surgery deposit.

Cancellation and Rescheduling Policy:


Cancellation and Rescheduling Policy:

Cancellation at ANYTIME prior to surgery date – 50% Refund of $1000 Deposit.

Cancellation at least 4 weeks (30 days) prior to surgery date – 100% Forfeiture of $1000 Deposit.

Cancellation once paid in FULL at two weeks (14 days) or less prior to surgery date – Forfeiture of 50% of Surgery cost.

There will be no funds held back in the event of rescheduling or cancellation by us, or in the event of a documentable medical reason with a treating doctor’s statement once reviewed and approved by Dr. Becker.



I understand that I, as a patient, am responsible for any and all costs assigned to me and my surgery, and fully agree to all deposit and payment terms listed above.


Please sign and return, thank you!!

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