Apply For Help
Volunteer Health Organizations, Children's Health Organizations

Patient Application (English)

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    • Step 5

    Applicant Information

    Thank you for your interest in applying to Fresh Start. Please indicate if you were referred by:

    Name *

    Applicant's Address *

    If not in the US, does the patient and parent have passport?

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    Parent/Guardian Information

    Parent/Guardian Name *


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    Description of Condition

    The following lists the surgical procedures perlabeled at Fresh Start. Please select the type of surgery or treatment needed:

    Physician's Name

    Physician's Phone

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    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:

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    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.

    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.

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