Surgical Application Form

Surgical Application Form

Application form for Fresh Start Surgical Gift Application For Medical Services. Fresh Start Surgical Gifts provides charities and care for children with physical deformities and other health problems through the gift of reconstructive services. Form Preview
  • Fresh Start Surgical Gift Application For Medical Services

  •  -  - Pick a Date
  •  -  - Pick a Date
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  •  -  - Pick a Date
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  • List Patient & Family Menbers / Income Source / Age / Relation to Patient

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    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.

     

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