You must have JavaScript enabled to use this form. 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