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

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:

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.

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.

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)