Patient Application (English)

Applicant Information
Name*
First Middle Last
Applicant's Address*
Street Address City State / Province / Region ZIP / Postal Code Country
County of Residence*
Country of Residence*
Country
If not in the US, does the patient and parent have passport?
- Yes
- No
Do the patient and parent have Visas?
Will you need transportation
Phone*
Email*
Applicant's Date of Birth*
Date Format: MM slash DD slash YYYY
Sex*
- Male
- Female
Applicant's Country of Citizenship
Country

Parent/Guardian Information
Parent/Guardian Name
First Last
Parent's / Guardian's Date of Birth*
Date Format: MM slash DD slash YYYY
Address same as patient?
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
County of Residence
Phone
Email
Sex of Parent/Guardian

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*
If you answered "Other," what is the condition?
Reason for condition*
- A congenital birth defect
- Accident or Trauma
- A violent act
- Not Applicable
Is the condition related to:
Other Health Problems:*
Allergies
Medications Currently Taking:
Physician's Name
First Last
Physician's Phone
Has the applicant received treatment for the condition?:*
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?*
If answered "yes", please specify type of insurance coverage
Have you been denied insurance for your condition?:

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 applicant, 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:*

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.
Drop files here or
Please attach current front and side-view photographs of problem area
Drop files here or

Accepted file types: jpg, png, gif, pdf.
Please attach copies of all medical records related to treatments you have received for your problem
Drop files here or

Accepted file types: jpg, png, gif, pdf.
Please attach copy of Patient's Birth Certificate
Drop files here or

Accepted file types: jpg, png, gif, pdf.
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.
Drop files here or

Accepted file types: jpg, png, gif, pdf.
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*
Date Format: MM slash DD slash YYYY

Tell us about you (17 year or older Applicants)
If the prospective patient is 17 years or older, you are required to upload a short essay which answers the following questions: (Please do not exceed 2 pages)
Who are you and what are your personal interests & work experience?
What is your educational background?
Why are you applying to Fresh Start?
How will this gift change your life?
What will you give back in return for the gift from Fresh Start?
Name
This field is for validation purposes and should be left unchanged.

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