Please read the following important program information and check each box to indicate you agree to the terms:
Additional financial assistance may be available if you provide proof of membership in one of the following assistance programs:
You must send a hard copy of this application (available here) with proof of financial need for consideration for the Free Fix program. Fax to 801-364-0374 or mail to: 324 S 400 W Ste C, SLC, UT 84101.
Our programs depend on donations to continue. PLEASE specify the amount you can contribute as a co-pay at the time of surgery. This will help ensure our programs are available to you in the future.