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 Anesthesia Deposit and Fees

Please review Insurance/Payment Information (Clickable Link) for Evergreen Dental Anesthesia’s detailed payment schedule

Instructions - please review and complete steps 1-3 below. Prior to your appointment, please also review and complete the Forms (Clickable Link) to complete the New Patient Registration Form and Informed Consent for Anesthesia.

  1. Review the fees for Pediatric Patients and Adult Patients*

2. Read and sign the financial agreement for Pediatric Patients or Adult Patients

3. Submit the required deposit for Pediatric Patients or Adult Patients**

*Anesthesia fees for Pediatric Patients and Adult Patients are listed below. The entire fee for the anesthesia services rendered is determined by the length of the surgery being performed. The final bill will be available as soon as the surgery is compete. Dr. Carillo currently accepts fee-for-service only. At the end of the procedure, a statement of anesthesia services will be provided to patients to help them submit to their private insurance if they choose to do so.

**Once the deposit is received your appointment will be confirmed. Full payment is required on the day of anesthesia.

Please don't hesitate to email Dr. Carillo at admin@evergreenda.com with any payment questions.

1. Anesthesia Deposit and Fees

Pediatric Patients (13 years old and younger)

Pediatric Fees

1. $950 fee for every case which is 2 hours or less

2. $600/hr billed in 15 minute increments for cases 2 hours or longer

Pediatric Deposit

There is a mandatory $300 deposit in order to hold the appointment. This amount will be applied towards your final bill after your procedure.

Adult Patients (14 years old and older)

Adult Fees

1. $600 for every case which is 1 hour or less

2. $600/hr billed in 15 minute increments for cases 1 hour or longer

Adult Deposit

There is a mandatory $500 deposit in order to hold the appointment. This amount will be applied to your final bill after your procedure.

2. Financial Agreement

Please review the appropriate financial agreement below. After reading through the agreement, return to this page and sign the financial agreement electronically below.

Evergreen Dental Anesthesia fees are separate from the dental/surgery fees. Evergreen Dental Anesthesia accepts all major credit cards and cash. Ask about a cash discount.

3. Mandatory Deposit

Please click the appropriate deposit below to be redirected to a page where you can submit your payment.

This amount will be applied towards your final bill after your procedure.


Custom Payment

You can submit the remainder of your payment by clicking the custom payment button below.