To request information, please answer the questions below and click on the button labeled "Send Request". Call Us You can contact us by calling: 801-213-2195 We will transfer you to the person you need. Questions? Ask us via email transgenderhealth@hsc.utah.edu. Requesting Information for Yourself or Someone Else? Requesting Information for Yourself or Someone Else? * - Select -SelfChild or MinorOther Adult Other Adult Chosen Name: Patient Legal First and Last Name: * Pronouns: Date of Birth: * basic address Address: City: State: - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code: Email Address: * Contact Number: * Extra Discretion Required (Please Specify if Needed): Relationship To Inquiring Person Self Parent/Guardian Partner/Spouse Friend Preferred Contact Method Email Phone myChart Preferred Contact Time: ÈËÆÞÖгöÊÓƵ Insurance? Yes No If Yes, Please Specify the Name of Your Insurance: Service you are Requesting (Please Check All that Apply) Adolescent Medicine Gender-Affirming Hormone Therapy or Primary Care Fertility Preservation (Sperm) Fertility Preservation (Eggs) Gender-Affirming Top Surgery (Chest Masculinization) or Bilateral Mastectomy Breast Augmentation Vaginoplasty or Vulvoplasty Phalloplasty or Metoidioplasty ObGyn or Hysterectomy Orchiectomy Gender-Affirming Facial Surgery or Tracheal Shave Revision of Past Gender-Affirming Surgery Other Gender-Affirming Surgery Mental ÈËÆÞÖгöÊÓƵ Hair Removal/ Esthetician Voice Therapy Other Needs (Fill in the blank) Other Needs (Fill in the blank) Reason For Requested Visit: Leave this field blank