Patient Contact | Face Gift Inc

First name

Last name

Email

Phone

Date of birth

Month

Day

Year

City & state

Which side of the face is affected?

Left

Right

Both

What caused the facial palsy, if known? (optional)

When did symptoms begin? (approximate is fine)

Has your condition improved on its own since it started?

Some improvement

No change

Getting worse

Anything else you'd like us to know? (optional)

Current physician's name and clinic, if any (optional)

Do you currently have health insurance?

Yes

No

Unsure

I consent to Uplifting Faces, Inc. contacting me by phone or email about my application and sharing my information with a partner surgeon to review my eligibility. I understand that submitting this form does not guarantee acceptance into the program.

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