Prospective Patient's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

Prospective Patient is:

Female

Male

If not in the US, does the patient and one parent have a Passports?

Patient - Yes

Patient - No

Parent - Yes

Parent - No

If not in the US, will the patient and parent need transportation?

Yes

No

Primary Language Spoken

English

Spanish

French

Other

Is this problem:

Related to a congenital birth defect

Related to an injury or accident

Caused by physical abuse

Caused by a violent act (police report needed if over age 21)

Physician's Name

First Name

Last Name

Physician's Phone

(###)

###

####

Has the prospective patient received any treatment for the problem?

Contact person needs to obtain copies of: 1) All medical records related to the condition 2) Current front and side-view photographs 3) In your own words, a story of medical treatments and how this condition affects the child 4) A copy of last Income tax filing The additional documentation and photographs should be e-mailed to Carol Ann Jacovich-Ochwat, Medical Program Coordinator, at CarolAnn@FreshStart.org. Incomplete applications will not be considered.

Yes

No

Does the patient have medical insurance coverage? *

If yes, please attach a copy of both sides of the insurance identification card and policy listing those services not covered. The additional documentation and photographs should be e-mailed to Carol Ann Jacovich-Ochwat, Medical Program Coordinator, at CarolAnn@FreshStart.org. Incomplete applications will not be considered.

Yes

No

Name of Parent/Guardian *

First Name

Last Name

Address of Parent/Guardian

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone of Parent/Guardian *

(###)

###

####

Parent/Guardian's Date of Birth

MM

DD

YYYY

Parent/Guardian's Gender:

Female

Male

Do You Rent or Own Your Home?

Rent

Own

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 reimbursement for the surgery requested of Fresh Start Caring For Kids Foundation.

Yes

No

Printed Name:

First Name

Last Name

Date

MM

DD

YYYY