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 comfortdentalanesthesia@gmail.com, or fax to (310) 578-1647.
Forms
Payment
*PLEASE READ BEFORE MAKING YOUR DEPOSIT PAYMENT: When processing your payment, please utilize the “Description” field to enter Patient Name and Date of Birth. Please utilize the “Company” field to enter your Office Location and Procedure Date. This will ensure your deposit is applied appropriately. Thank you!
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 have any questions, please contact our office at (310) 570-9941.
$1500 Facial Surgery Deposit
$500 Adult Anesthesia Deposit
$300 Pediatric Anesthesia Deposit
Custom Payment Amount
Forms Español