Second Opinion Application

PLEASE NOTE
This form is offered online for your convenience.  If you prefer to fill it out the old fashioned way, please download or print it here.

Also, we understand that you may not be comfortable uploading the requested documents, or maybe you don’t have access to a scanner. In those cases, feel free to fill out the application online, and send in copies of documentation.  They can be mailed to Circle of Hope Inc., 23033 Lyons Avenue, Suite 3, Newhall, CA  91321 or faxed to (661) 254-5255.

Please give us a call at (661) 254-5218 if you have any questions or concerns.

Step 1 of 4

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  • Applicant Information

    Note: Circle of Hope will pay directly to your choice of facility or doctor.
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
  • US citizenship or permanent legal residency is a requirement of eligibility.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf.

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