Candidate Submission Form

Surgical Candidate Submission Form

** Please note, due to the high volume of inquiries, we cannot guarantee all submissions will be approved for surgery**

All Submissions Due by January 27th, 2023

Please complete the following information as thoroughly as possible. A representative from either CSOG or CCOE will be in contact to further discuss your candidacy request and next steps between December 27th - February 3rd.

First Name *

Last Name *

Date of Birth *

Email *

Phone *

I am over the age of 18

Yes

No

Do you have Insurance? *Please note, to qualify you must NOT have active insurance and must NOT qualify for any government or state assistance programs *

I am currently Insured

I am eligible for Government Assistance

I am currently Uninsured

Side of Body Injury Is On *

Left

Right

Both Left and Right

Please tell us about your symptoms and how your injury occured *

Surgical Candidate Submission Form

All Submissions Due by January 27th, 2023

Please complete the following information as thoroughly as possible. A representative from either CSOG or CCOE will be in contact to further discuss your candidacy request and next steps between December 27th - February 3rd.

4110 Briargate Parkway, Suite 200

Colorado Springs, CO 80920

Monday – Friday 8am-5pm