Download The Form

  • 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.

  • Photo (maximum upload 3 jpg or png images)
  • Parent's Information

  • Insurance Information

  • Patient Medical Information

  • Please indicate whether you agree to the Terms of Use and Privacy Policy by selecting the appropriate button below. By selecting "I Agree" you acknowledge that you have read, understand, agree to and are bound by our Terms of Use. It is the goal of the Faces Foundation to provide services for facial surgery and/or reconstruction at no-cost to you. If you are selected, the expectation is that, your family and or friends, will “Pay-it-Forward” by donating your/their time to partnering non-profit organizations in the community. It is understood that the “Pay-it-Forward” time commitment will be documented and completed prior to scheduling approved surgery. It is also understood that submitting the application form does not imply automatic selection as a surgery recipient.