Apply For Help

Applicant Information

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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 AntonioGoogle SearchSocial MediaNews ProgramOther

Name *

Applicant's Address *

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
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

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Parent/Guardian Information

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Parent/Guardian Name *

Parent's Guardian's Date of Birth *

Address same patient? *
—Please choose an option—YesNo
Sex of Parent/Guardian
MaleFemale

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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:

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Related Conditions/Other Health Problems: * Allergies Medications Currently Taking:

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Has the applicant received treatment for the condition?: * YesNo Have you been denied insurance for your condition?: YesNo

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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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Family Member Names *

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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.

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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.

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Signature * Date *

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