Surgical Application Form

Todays Date:*

MonthDayYear

Patients Full Name*

First NameLast Name

Gender*

FemaleMale

DOB*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Language

Citizenship

If not in the US, do patient and parent have passports and visas?

Condition*

Briefly describe type of surgery or treatment needed and why:*

Is the problem :

a) Related to a congenital birth defect.b) Related to accident or traumac) Caused by physical abuse.d) Caused by violent act.

Other health problems?

Pictures*

Has the prospective patient ever received any treatment for the problem? If yes, please attach all medical records.

Medical Records

Does the patient have medical insurance coverage?

YesNo

If yes, specify type:

Was surgery or treatmnet denied by medical insurance?

YesNo

If yes, please submit denial letter.

Parents Full Name*

First NameLast Name

Parents DOB

MonthDayYear

E-mail*

Phone Number

Area CodePhone Number

List Patient & Family Menbers / Income Source / Age / Relation to Patient

Click to edit

How did you hear from Fresh Start?*

Please include everything listed below (if applicable) for faster processing:*

Please return completed application along with current
front and side view photographs to the address above. Photographs become the property of Fresh
Start Surgical Gifts, Inc. and cannot be returned. Applications without photographs cannot be
processed. Please call Shelley at (760) 944-2012 e-mail: shelley@freshstart.org
for more information.

I declare under the penalty
of perjury that the foregoing is a true and accurate statement as to the
availability of any insurance or state funded reimbursements for the surgery
requested of Fresh Start Surgical Gift, Inc.

Signature*

Fresh Start Surgical Gift Application For Medical Services