Please fill out the application entirely, sign the photo release and consent release at the end of the document (last two pages), and include the following items:
A recent photograph of the patient – photograph will not be returned
A copy of any medical history/records on the patient
The name and contact information for the attending plastic surgeon and the primary care physician/pediatrician
A letter from the attending plastic surgeon, confirming appointment date, surgical treatment plan/procedures and estimated length of stay
A copy of your most recent IRS tax return, if you are applying from within the United States
A copy of your most recent check stub
You must complete and return the Application for Assistance 4 to 6 weeks in advance of the date of travel. Medical emergencies will be the only exception, and declaration of emergency must come in writing from the attending plastic surgeon and/or the primary care physician/pediatrician.
After the operation, you will be required to provide another set of photos of the patient.
For assistance in completing your application, or to be matched with a craniofacial plastic surgeon and/or craniofacial center,
Please call us at +1 972 566 6669 or Toll-free in the U.S. at 800 533 3315.