4700 S. Wadsworth Blvd.                                                                                                                                                                                     Phone: (303) 932-6914
Littleton, Colorado 80123                                                                                                                                                                                    Fax: (303) 932-1124

Cold Therapy

Your Physician may have suggested a Cold Therapy unity and/or pain pump to be used following your upcoming surgery. These items are used to help manage pain and swelling and aid in your recovery.  Most insurance companies view these items as not medically necessary; therefore they do not pay for these items.  Your Physician may arrange for you to purchase a Cold Therapy Unit, and/or purchase the Pain Control Pump with special discounted pricing through Total Orthopedics, Inc.  The cost to purchase the Cold Therapy Unit is $175.The cost of the pain pump is $195.  If you would like either or both of the items recommended by your physician please fill out the form below.


Cold Therapy/Pain Pump

Please Fill out the form below and press submit.


Patient Name: *
Phone Number: *
Billing Address: *
Location of Surgery (Facility): *
Date of Surgery: *
Doctor: *
 Surgical Procedure:
KneeShoulderAnkle/FootHipOther
If other:
 If you would like to decline this offer, please check mark this box and press submit.
Decline
 DonJoy IceMan Cold Therapy Unit:
Purchase ($175)

 DonJoy Iceman Cold Therapy Additional Items:

Replacement Pad ($45)  
Y-Connector ($25)
 Pain Pump:
Pain Control Pump ($195)
 Method Of Payment:
VisaMasterCardDiscover          
AmEx
Card Number:
Exp Date:
Security Code (3 or 4 digits):
Name on Card:
  Want receipt emailed
Email Address to email receipt:
Security Code: *  

Contact Information

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Contact Information

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Contact Information

In this area, you can enter text about your contact form. You may want to explain what happens after a visitor submits the form and include a contact phone number.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
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Evening Phone:
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