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ovCufWAX2w5D63ufrhtiwVmg29gkMInDVypcG5jYRwp

Contact Us Form

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Please answer all following questions and submit all the information you are able to at this time. You may return and update your submission and submit at a later time if you have more information you can provide us up front.

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Legal Name (first and last names on your ID and/or insurance card)

* must provide value

Name (first and last names)

* must provide value

Pronouns

* must provide value

he/him/his

she/her/hers

they/them/theirs

other (please clarify in comment section at the end)

Phone Number

* must provide value

Email Address

* must provide value

Address

* must provide value

City / Province

* must provide value

State

* must provide value

ZIP / Postal Code

* must provide value

How did you find out about University Gender Affirmation Surgery?

* must provide value

I found it online

I was referred by a medical or mental health professional

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Name of your Primary Care Physician or HRT-prescriber

Primary Care Physician Phone Number

Have you started Hormone Replacement Therapy (HRT)?

* must provide value

Yes

I was on HRT but am not currently

I am starting HRT soon

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If you are currently on HRT or have been on it recently, please tell us your start date here.

D-M-Y

Have you discussed gender-affirming surgery with your doctor?

* must provide value

Yes

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Do you have one or more WPATH letters from a gender therapist?

* must provide value

Yes

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If you have a WPATH letter, please attach it here.

If you have more than one, please attach them all by selecting them from your files by clicking one then the other(s) by first tapping the Shift key. This will allow you to submit multiple files at once. Otherwise please attach the second image at the end of the survey.

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Height

* must provide value

Weight

* must provide value

BMI

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Date of Birth

M-D-Y

Today's Date

M-D-Y

Age

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Desired Surgery Type (check all that apply)

* must provide value

FTM / Non-Binary Top Surgery

Combined FTM Top Surgery & Hysterectomy (requires 12 months HRT)

MTF Top Surgery

Penile Inversion Vaginoplasty

Zero-Depth Vaginoplasty

Orchiectomy

Orchiectomy with Scrotoplasty

Labiaplasty

Other

Do you have insurance you want to use for surgery?

* must provide value

Yes

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If you will be using insurance, please upload the front AND back of your card here.

If you have more than one photo to upload, please attach them all by selecting them from your files by clicking one then the other(s) by first tapping the Shift key. This will allow you to submit multiple files at once. Otherwise please attach the second image at the end of the survey.

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Please attach the BACK OF YOUR INSURANCE CARD here if not attached above.

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How may we contact you?

* must provide value

YES, you may CALL me in the MORNING

YES, you may CALL me in the AFTERNOON

YES, you may leave me a VOICEMAIL at the number I provided

NO, you may not call me

YES, you may email me

When reaching out to you on your preferred contact method, what name do you prefer that we use?

Have you consulted with another surgeon for your desired surgery?

* must provide value

Yes

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If you called your insurance company and requested an Explanation of Benefits or have a downloaded copy of it, please attach it here. This lists the eligible surgeries and policies and will speed up your benefits check process.

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Additional Comments

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Patient E-Mail Usage Consent: By typing your full name below, it serves as an electronic signature to consent to contact via email. Please see below for details before giving consent. If you do not consent, please write, "I DO NOT CONSENT."

* must provide value

E-mail may be used to communicate about scheduling, surgery, insurance and billing information. I understand email is a substitute for other forms of communication and that email should never be used for emergency situations or urgent problems. In the event of an emergency, I will call 911 or go to an emergency room, urgent care, or immediate care facility. Risks include circulating email, email broadcast, human error, falsification of information, backed-up or archived copies after a message is deleted, interception and transfer of information, viruses, and emails as legal documents in a court of law. IU Health takes the following precautions to protect your protected health information: identifiable information is never forwarded to a third party except for treatment, payment, or healthcare operations purposes without your express permission, patient emails are never given for marketing purposes, professional emails are not shared with patient's family members, emails are backed up and archived regularly, and patient email addresses are verified prior to sending the message with a confidential indicator attached for the recipient. By signing, I agree to indemnify and hold harmless the provider, his or her medical practice, IU Health Physicians, and its trustees, officers, directors, associates, agents, information providers, suppliers, and website designers and maintainers from and against all losses, expenses, damages and costs, including reasonable attorney fees, relating to or arising from any information loss due to technical failure, my use of the internet to communicate with the provider, the use of the provider's website, any arrangements I make based on the information obtained at the site, any products or services obtained at the site, and any breach by me of these restrictions and conditions. The provider does not warrant that the functions contained in any materials provided will be uninterrupted or error-free, that defects will be corrected, or that the provider's website or server that makes such site available is free of viruses or other harmful components. I understand there may be times in which the provider must forward the information I have provided via email to a third party for billing, treatment, or payment purposes. I expressly provide my consent by signing below for the provider to forward these emails to a third party under these conditions and evidence my consent by signing below. I have the right to revoke this consent, in writing, at any time by presenting the written revocation to my healthcare provider. The provider shall have the right to immediately terminate the email relationship with me if he or she determines, in her or her sole discretion, that I have violated the terms and conditions set forth in the Agreement or have engaged in conduct which the provider determines to be unacceptable. By typing my full name below, I hereby consent to the use of emails as a means of communication between an IU Health Physicians provider, his or her office staff, and myself. I understand the inherent limitations related to electronic communications, understand the limits of email transactions, hold harmless IU Health Physicians for loss of information due to technical failures and consent to these conditions and terms.

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