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Give an Ear Foundation - Tagline

IMPORTANT INFORMATION

  1. This Application Form is for Patients who consider to join our waiting list of candidates for Corrective Surgery for Microtia/Atresia.
  2. Candidates are automatically shortlisted for pre-medical evaluation and examination, when available.
  3. This does not constitute a guarantee of surgery procedure, but a big step towards the repair of Microtia/Atresia in candidate.
  4. We are a Non-Profit Charity Organization and so depend solely on donations and sponsorships.
  5. Make sure you have at least 3 photos (front view, left ear view and right ear view) of patient before you start filling this form.

Application Form

Please fill this Application form and we'll get back to you shortly.
  • APPLICANT (PATIENT) INFORMATION

  • APPLICANT/GUARDIAN INFORMATION

  • Please use international format, if outside South Africa
  • Please use international format, if outside South Africa
  • DESCRIPTION/HISTORY OF PATIENT'S CONDITION

  • Please enter Name of Doctor, Name and Address of Hospital, Phone numbers, email address, etc. This will help us with our medical background investigation and medical history.
  • Drop files here or
    Please Upload Photo of minimum of three photos, including (1). Front/Face View, (2). View of Left Ear and (3). View of Right Ear.
  • PATIENT'S FINANCIAL BACKGROUND

  • This is person or Organization financial responsible for patient, including patients feeding, school fees (If any), etc.
  • What does this person/Organization do get income?
  • Financial Contribution here, we mean partial or full cost of surgical procedure.
  • ADDITIONAL INFORMATION

OUR SUCCESS STORIES

VICTOR IFEANYI NWADIKE

(REFERENCE NO.: GAEFP 001)

Date of birth: 22nd May 2008
Gender: Male
Location: Lyndhurst, Johannesburg, South Africa.
Case Description: Single Sided (Left) Grade 3 Microtia/Atresia

 

Victor Ifeanyi Nwadike was born with a grade 3 single-sided (Left) Microtia and Atresia (under-developed outer ear and no ear canal). He needed to undergo surgery to reconstruct his outer ear and open the ear passage. He had been offered a FREE re-constructive surgery by Fresh Start Surgical Gifts, USA and was scheduled to San Diego, California, USA in July 2015. THAT TRIP HAPPENED!

11th JULY 2015: VICTOR RECEIVES STAGE ONE MICROTIA SURGERY IN SAN DIEGO CALIFORNIA, USA, courtesy of FRESH START SURGICAL GIFTS (Sponsored Flight was from South African Airways - SAA). Surgeon was Dr. Michael Brucker.

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