The information provided on this form is intended solely for appointment and scheduling purposes at the designated location. By selecting this button, you acknowledge your full understanding and consent regarding the purposes of this form. You furthermore acknowledge that all information provided regarding yourself and parties involved is correct and accurate.

Surgical Specialists of Colorado maintains the right to use this form to schedule appointments. Surgical Specialists of Colorado protects patient confidentiality as well as any personal or health related information unless expressed consent or legal obligation is produced. Confidential information includes diagnosis, treatment, medication, personal information, symptoms, and care plans. All information given is done freely and will full knowledge and consent of the patient or legal representative.