Patient Application (English) Step 1 Step 2 Step 3 Step 4 Step 5 Applicant Information Thank you for your interest in applying to Fresh Start. Please indicate if you were referred by: Rady Children's HospitalComer Children's HospitalHospital Infantil De Las CaliforniasSanford HealthUniversity Health in San AntonioOPSAM HealthTrue CareGoogle SearchSocial MediaNews ProgramOther Name * First Middle Last Applicant's Address * Street Address City State / Province / Region ZIP / Postal Code United StatesAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustrailiaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandsCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIragIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalwaiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipleSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbar and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuataVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country County of Residence * Country of Residence * United StatesAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustrailiaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandsCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIragIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalwaiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipleSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbar and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuataVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe If not in the US, does the patient and parent have passport? YesNo Do the patient and parent have Visas? YesNoN/A Will you need transportation YesNoN/A Phone * Email * Applicant's Date of Birth * Sex * —Please choose an option—MaleFemale Applicant's Country of Citizenship United StatesAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustrailiaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandsCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGeorgiaGermanyGhanaGibraltarGreeceGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIragIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalwaiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipleSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbar and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuataVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Required Fields Missing Next Parent/Guardian Information Parent/Guardian Name * First Last Parent's Guardian's Date of Birth * Address same patient? * —Please choose an option—YesNo Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code [select pg-country default:"United States" "Afghanistan" "Aland Islands" "Albania" "Algeria" "American Samoa" "Andorra" "Angola" "Aguilla" "Antarctica" "Antigua and Barbuda" "Argentina" "Armenia" "Aruba" "Austrailia" "Austria" "Azerbaijan" "Bahamas" "Bahrain" "Bangladesh" "Barbados" "Belarus" "Belgium" "Belize" "Benin" "Bermuda" "Bhutan" "Bolivia" "Bonaire, Sint Eustatius and Saba" "Bosnia and Herzegovina" "Botswana" "Bouvet Island" "Brazil" "British Indian Ocean Territory" "Brunei Darrussalam" "Bulgaria" "Burkina Faso" "Burundi" "Cambodia" "Cameroon" "Canada" "Cape Verde" "Cayman Islands" "Central African Republic" "Chad" "Chile" "China" "Christmas Islands" "Cocos Islands" "Colombia" "Comoros" "Congo, Democratic Republic of the" "Congo, Republic of the" "Cook Islands" "Costa Rica" "Cote d'Ivoire" "Croatia" "Cuba "Curacao" "Cyprus" "Czech Republic" "Denmark" "Djibouti" "Dominica" "Dominican Republic" "Ecuador" "Egypt" "El Salvador" "Equatorial Guinea" "Eritrea" "Estonia" "Eswatini (Swaziland)" "Ethiopia" "Falkland Islands" "Faroe Islands" "Fiji" "France" "French Guiana" "French Polynesia" "French Southern Territories" "Gabon" "Georgia" "Germany" "Ghana" "Gibraltar" "Greece" "Guadeloupe" "Guam" "Guatemala" "Guernsey" "Guinea" "Guinea-Bissau" "Guyana" "Haiti" "Heard and McDonald Islands" "Holy See" "Honduras" "Hong Kong" "Hungary" "Iceland" "India" "Indonesia" "Iran" "Irag" "Ireland" "Isle of Man" "Israel" "Italy" "Jamaica" "Japan" "Jersey" "Jordan" "Kazakhstan" "Kenya" "Kiribati" "Kuwait" "Kyrgyzstan" "Lao People's Democratic Republic" "Latvia" "Lebanon" "Lesotho" "Liberia" "Libya" "Liechtenstein" "Lithuania" "Luxembourg" "Macau" "Macedonia" "Madagascar" "Malwai" "Malaysia" "Maldives" "Mali" "Malta" "Marshall Islands" "Martinique" "Mauritania" "Mauritius" "Mayotte" "Mexico" "Micronesia" "Moldova" "Monaco" "Mongolia" "Montenegro" "Montserrat" "Morocco" "Mozambique" "Myanmar" "Namibia" "Nauru" "Nepal" "Netherlands" "New Caledonia" "New Zealand" "Nicaragua" "Niger" "Nigeria" "Niue" "Norfolk Island" "North Korea" "Northern Mariana Islands" "Norway" "Oman" "Pakistan" "Palau" "Palestine, State of" "Panama" "Papua New Guinea" "Paraguay" "Peru" "Philippines" "Pitcairn" "Poland" "Portugal" "Puerto Rico" "Qatar" "Reunion" "Romania" "Russia" "Rwanda" "Saint Barthelemy" "Saint Helena" "Saint Kitts and Nevis" "Saint Lucia" "Saint Martin" "Saint Pierre and Miquelon" "Saint Vincent and the Grenadines" "Samoa" "San Marino" "Sao Tome and Principle" "Saudi Arabia" "Senegal" "Serbia" "Seychelles" "Sierra Leone" "Singapore" "Sint Maarten" "Slovakia" "Slovenia" "Solomon Islands" "Somalia" "South Africa" "South Georgia" "South Korea" "South Sudan" "Spain" "Sri Lanka" "Sudan" "Suriname" "Svalbar and Jan Mayen Islands" "Sweden" "Switzerland" "Syria" "Taiwan" "Tajikistan" "Tanzania" "Thailand" "Timor-Leste" "Togo" "Tokelau" "Tonga" "Trinidad and Tobago" "Tunisia" "Turkey" "Turkmenistan" "Turks and Caicos Islands" "Tuvalu" "Uganda" "Ukraine" "United Arab Emirates" "United Kingdom" "United States" "Uruguay" "US Minor Outlying Islands" "Uzbekistan" "Vanuata" "Venezuela" "Vietnam" "Virgin Islands, British" "Virgin Islands, U.S." "Wallis and Futuna" "Western Sahara" "Yemen" "Zambia" "Zimbabwe"] Country County of Residence Phone Email Sex of Parent/Guardian MaleFemale Required Fields Missing Previous Next Description of Condition The following lists the surgical procedures perlabeled at Fresh Start. Please select the type of surgery or treatment needed: Select Closest Condition * MicrotiaScar RevisionsOtoplastyCleft Lip & Palate RepairSepto-RhinoplastyLefort I, II, IIIMandibular & Maxillary OsteotomiesExcisions of lesions with/out tissue expandersBurn contracture procedurePolydactyly hands & feetTongue ReductionGynecomastiaPoland Syndrome ReconstructionStrabismus & other eye proceduresTreacher-Collins Syndrome ProceduresLaser Procedures for Vascular LesionsFacial Hypoplasia ProceduresOther If you answered "Other", what is the condition? Reason for condition * —Please choose an option—A congenital birth defectAccident or TraumaA violent actNot ApplicableOther Related Conditions/Other Health Problems: * Allergies Medications Currently Taking: Physician's Name First Last Physician's Phone Phone Has the applicant received treatment for the condition?: * YesNo If the answer is "yes", describe all previous treatments Briefly describe type of surgery or treatment needed and why? Does the prospective patient have medical insurance coverage? * YesNo If answered "yes", please specify type of insurance coverage Have you been denied insurance for your condition?: YesNo Required Fields Missing Previous Next Household Information Please list names of patient & family members. Include the income source/type of employment for each family member, their age, relationship to the applciant, their gross yearly income, and if he/she is a dependent: Family Member Names * Total Household Gross Annual Income: * Amount of Monthly Expenses: * Total Amount of Assets: * Total Amount of Liabilities: * Required Fields Missing Previous Next Image / Documents Please attach: medical records, photographs, insurance information/denial letter. Applications without photographs cannot be processed. Please call (760) 448-2023 for more information. Please avoid blurry images and make sure these images are legible. If you answered "yes" to denial of insurance coverage, please upload a copy of the denial letter. Please attach current front and size-view photographs of problem area Please attach copies of all medical records related to treatments you have received for your problem Please attach copy of Patient's Birth Certificate If a US citizen, please attach a copy of the most current filed IRS tax return. Provide only the 1040 forms. Please omit your social security number. Signature and Date 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 * Date * Required Fields Missing Previous