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.
I am over the age of 18
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 *
Injured Area *
Side of Body Injury Is On *