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IMPORTANT INFORMATION

This Application Form is for Patients who consider to join our waiting list of candidates for Corrective Surgery for Microtia/Atresia.
Candidates are automatically shortlisted for pre-medical evaluation and examination, when available.
This does not constitute a guarantee of surgery procedure, but a big step towards the repair of Microtia/Atresia in candidate.
We are a Non-Profit Charity Organization and so depend solely on donations and sponsorships.
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.

How did you hear about us?*
Do you understand that the information you are about to share here may be made public, Including patients photos?*
Do you give us permission to publicly use relevant patient information (including photos) where necessary?*
APPLICANT (PATIENT) INFORMATION
Full Name of Patient*
First Middle Last
Address of Patient*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth (Patient)*
Gender of Applicant*
Country of Origin of Patient*
APPLICANT/GUARDIAN INFORMATION
Relationship with Patient*
Full Name of Parent/Guardian*
First Middle Last
Address of Patient*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender of Parent/Guardian*
Date of Birth (Parent/Guardian)*
Email Address*
Enter Email Confirm Email
Mobile Phone Number*
Please use international format, if outside South Africa
Office Phone Number (If Any)
Please use international format, if outside South Africa
Country of Origin (Parent/Guardian)*
Name of Employer (If Any)
Website (If Any)
DESCRIPTION/HISTORY OF PATIENT'S CONDITION
Type of Ear Defect*
Location of Ear Defect*
Origin of Ear Defect*
Has Applicant ever received Medical Attention?*
Medical Personnel/Location Details (If Applicable)
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.
Upload Photo of Condition (Minimum of 3 pix)*
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
Name of Person/Organization Responsible (For Patient)*
This is person or Organization financial responsible for patient, including patients feeding, school fees (If any), etc.
Occupation of Person/Organization Responsible (For Patient)*
What does this person/Organization do get income?
Are both Parents of the Applicant Alive?*
Does Patient directly have a medical cover?*
Is/Are Patient's Parent(s)/Sponsor(s) able some Financial Contribution?*
Financial Contribution here, we mean partial or full cost of surgical procedure.
ADDITIONAL INFORMATION
Enter additional information here:*
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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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IMPORTANT INFORMATION

Application Form

APPLICANT (PATIENT) INFORMATION

APPLICANT/GUARDIAN INFORMATION

DESCRIPTION/HISTORY OF PATIENT'S CONDITION

PATIENT'S FINANCIAL BACKGROUND

ADDITIONAL INFORMATION

OUR SUCCESS STORIES

VICTOR IFEANYI NWADIKE

(REFERENCE NO.: GAEFP 001)