REFERRAL FOR GENDER AFFIRMING CARE COORDINATION CLIENT NAME PLEASE

Date of referral (YYYY-MM-DD)

Phone: 1-866-999-1514

Fax completed form to: 604-675-7464

CLIENT DETAILS

Last name:

     

First name:

     

Legal name (as appears on CareCard):

       

Pronouns:

     

PHN:

     

Date of birth (YYYY-MM-DD):

     

Under 18yrs?

Address:

     

City:

     

Province:

      

Postal Code:

         

Email:

          

Primary phone:

     

Ok to leave message?

Yes No

Phone type:

Home Work

Cell Other

Alternate phone:

     

Ok to leave message?

Yes No

Phone type:

Home Work

Cell Other

Primary language:

     

Interpreter required?

Yes No

PROVIDER INFORMATION

Referring Physician

Primary care provider (if different from referring physician)

Name:

     

Name:

     

Role:

     

Address:

     

Phone:

     

Phone:

     

Fax:

     

Fax:

     

REFERRAL DETAILS

1. ELIGIBILITY CRITERIA. Has the client:

Completed all required surgical assessments (PLEASE ATTACH)

Assessment 1 Date: (YYYY-MM-DD)      

Assessment 2: Date (YYYY-MM-DD)      

Has had a hysterectomy/BSO (if required for lower genital reconstruction)

     

Have a plan in place for hair removal (as required by surgeon)

     

Able to travel to the US (valid passport and able to enter the US)

     

2. PREFERED SURGEON (if known)

Dr. Curtis Crane, Brownstein & Crane

(Austin Texas)

Dr. Loren Schecter, University Plastic Surgery

(Morton Grove, Illinois)

Undecided / Don’t know

     

4. Has client had lower masculinizing surgery before?

No Yes (YYYY-MM-DD)      

     

5. Does client currently have an appointment booked for lower masculinizing surgery?

No Yes Surgery date (if already booked): (YYYY-MM-DD)      

6. Type of surgery requested:

Phalloplasty Metoidioplasty Clitoral release Surgery revisions (describe):      

Stage :      

     

Additional information

7. Do you have any concerns regarding the stability of your client’s physical or mental health while travelling to the US for surgery?

No Yes If yes, please describe:      

8. Comments/additional information:

     

PROVIDER SIGNATURE

Provider name:

     

Signature

     

Date (yyyy-mmm-dd)