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Patient Application
Patient Information
ALL FIELDS MUST BE FILLED OUT. IF ANY QUESTION DOES NOT APPLY, WRITE “NA” IN THAT FIELD OR WE CANNOT PROCESS THE APPLICATION. LBFF is not responsible for healthcare issues of family members who accompany children.
How did you hear of Little Baby Face Foundation?
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Doctor
Friend
Television
News Article
Search Engine
Facebook
YouTube
Twitter
Blog
Other
Name
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First Name
Last Name
Sex
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Male
Female
Address
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Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Age
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(mm/dd/yyyy)
Date of Birth (MM/DD/YYYY)
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(mm/dd/yyyy)
Photo
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Photo (maximum upload 3 jpg, png, or gif images): Submitting a photo is strongly recommended and expidites the review and selection process. Applications without a photo may be delayed.
Phone
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Email
Verify Email
Does the child have a valid passport?
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Your answer is only used to better schedule our services.
Yes
No
Does the guardian have a valid passport?
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Your answer is only used to better schedule our services.
Yes
No
Parent's Information
Mother's Name
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First Name
Last Name
Employer's Name
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Address (if different from Patient)
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Yearly Salary
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Email
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Verify Email
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Home Phone
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Cellphone
*
Father's Name
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First Name
Last Name
Address (if different from Patient)
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Employer's Name
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Yearly Salary
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Email
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Verify Email
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Home Phone
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Cellphone
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Insurance Information
Do you have health insurance?
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Yes
No
If YES, which type of insurance?
Medicaid
Private Insurer
Name of Insurance Company
Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Name of Insured
Policy #
Patient Medical Information
Condition
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select one
Atresia (Deformed Ear Canal)
Bite Abnormalities or Buck Teeth
Cleft Lip/Cleft Palate
Crossed Eyes
Ear Deformity
Eyelid Lesions
Eyelid Ptosis
Facial Atrophy
Facial Cleft (Opening or Gap in the Face)
Facial Hemangloma (Facial Tumor)
Facial Paralysis or Facial Palsy
Facial Swelling
Facial Vascular Lesions
Hemifacial Microsomia (Deformed Face or Jawbone)
Lantern Jaw
Microtia (Small, Abnormally Shaped or Absent Ear)
Nasal Atresia (Blockage of the Nasal Passage)
Nasal Cleft
Nasal Swelling
Nose Deformity
Other
Describe Child's Condition
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Describe any medical or surgical procedures/treatment received to date
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