Contact Us

Use the form on the right to contact the Fresh Start Caring For Kids Foundation if you have questions about the website, donating, medical services, applying for help or volunteering. We appreciate your feedback!

444 E Algonquin Rd
Arlington Heights, IL, 60005
United States

844-374-5437

Fresh Start Caring For Kids Foundation provides no-cost medical treatment to children with physical deformities through the gift of reconstructive surgery and related medical care.

Patient Application (English)

Children in need of reconstructive surgery are encouraged to apply.

Prospective Patient's Name *
Prospective Patient's Name
Address
Address
Phone
Phone
Date of Birth *
Date of Birth
Prospective Patient is:
If not in the US, does the patient and one parent have a Passports?
If not in the US, will the patient and parent need transportation?
Primary Language Spoken
Is this problem:
Name of Parent/Guardian *
Name of Parent/Guardian
Address of Parent/Guardian
Address of Parent/Guardian
Primary Phone of Parent/Guardian *
Primary Phone of Parent/Guardian
Parent/Guardian's Date of Birth
Parent/Guardian's Date of Birth
Parent/Guardian's Gender:
Physician's Name
Physician's Name
Physician's Phone
Physician's Phone
Has the prospective patient received any treatment for the problem? (Contact person will need to obtain copies of all medical records and current front and side-view pictures.)
Does the patient have medical insurance coverage? *
$
Do You Rent or Own Your Home?
$
$
$
$
$
$
$
$
$
$
$
$
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.
Printed Name:
Printed Name:
Date
Date

Fresh Start Caring For Kids Foundation may require additional information.  If you have questions, please contact Fresh Start at (844) 374-5437.