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 the anesthesia. Both the facility and 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 the time we have reserved on your behalf. The Surgical Deposit 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.

l understand that once my surgery is scheduled with Dr. Becker and the operating room is reserved at a specific time for me, and is no longer available to other patients. Therefore, I agree to submit a $1,000 surgical deposit at the time I request my surgery to be scheduled. All surgical fees must be paid one week prior to the date of your surgery. The operating room and anesthesia fees are all included in your total cost to Dr. Becker.

Cancellation and Rescheduling Policy:

Cancellation at least 4 weeks prior to surgery date Full Refund of Deposit.

Cancellation less than 2 weeks prior to the surgery date Forfeiture of $1,000 Deposit.

Cancellation 3 days or less prior to surgery - 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.

I UNDERSTAND AND AGREE TOTHE ABOVE TERMS Please sign and return. Thank you .

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