Reconstructive Surgery for Children - Fresh Start Application

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
Phone
This field is for validation purposes and should be left unchanged.

Patient Application (English)