Other Ways to Apply



CLICK HERE for a PDF application you can print and mail or fax.

CLICK HERE for a simple text file you can return by email.

This site provides educational information only and is not intended to create a physician patient relationship.

Medical Records and Photos

Whichever way you apply, we ask that you also submit a photo and any available medical records by email to info@littlebabyface.org OR mail to LBFF, 135 East 74th St., New York, NY 10021.

Parent’s Information

When filling out the parent’s information you only need to fill out an address if it is different from the patient’s address.

Patient Application

ALL FIELDS MUST BE FILLED OUT. IF ANY QUESTION DOES NOT APPLY, WRITE "NA" IN THAT FIELD OR WE CANNOT PROCESS THE APPLICATION.

How Did You Hear of Little Baby Face Foundation?

A name is required.

A name is required.
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A value is required.
   
Patient’s Name:
A name is required.
Age: An age is required.
Sex: M    F
Date of Birth: A date is required.
Address:
An address is required.
City:
A city is required.
State: A state is required.
Zip Code: 
A value is required.
Country:
A country is required.
PARENT’S INFORMATION
Mother’s Name:
A name is required.
Address:
An address is required.
City:
A city is required.
State: A value is required.
Zip Code: 
A zip is required.
Home Phone:
A phone is required. Work Phone:  A phone is required.
Cell Phone:
A phone is required. Country:  A country is required.
Email:
An email is required.
Employer’s Name:
A name is required.
Employer’s Address:
An address is required.
Yearly Salary:
A number is required.  How long have you had this position? 
A number is required.
If less than a year, previous position: 
A number is required.
Father’s Name:
A name is required.
Address:
An address is required.
City:
A city is required.
State: A state is required.
Zip Code: 
A value is required.
Home Phone:

A phone is required.		  Work Phone: 
A phone is required.
Cell Phone: A phone is required.A phone is required.
Country:
A country is required.  
Email: An email is required.
Employer’s Name: A name is required.
Employer’s Address: An address is required.
Yearly Salary:
A number is required. How long have you
had this position? 		 A number is required.
If less than a year, previous position: 
A number is required.
PRIMARY CARE PHYSICIAN
Physician’s Name:
A name is required.
Address:
An address is required.
City:
A city is required.
State: A state is required.
Zip Code: 
A zip is required.
Phone: A phone is required.A phone number is required.
 Country:
A country is required.
Email:
An email is required.
INSURANCE INFORMATION

Do you have insurance?   Yes    No  

If yes, which type of insurance?   Medicaid    Private Insurer  

Please complete the following if you have insurance::
Name of Insurance:
A name is required.
Address:
An address is required.
City:
A city is required.
State: A value is required.
Zip Code: 
A zip code iis required.
Policy#:
Policy number is required.
Name of Insured:

A name is required.
PATIENT MEDICAL INFORMATION
Describe child’s condition:
 
A description is required.
Describe any medical or surgical procedures/treatment received to date:
 
A description is required.

LBFF is not responsible for healthcare issues of family members who accompany children.