Request An Appointment | University of Utah Health

To request information, please answer the questions below and click on the button labeled "Submit".

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?

Chosen Name

Patient Legal First and Last Name

Pronouns

Date of Birth:

Address

City

State

Postal Code

Email Address

Phone Number:

Extra Discretion Required (Please Specify if Needed:

Relationship To Inquiring Person: Self
Parent/Guardian
Partner/Spouse
Friend

Preferred Contact Method: Email
Phone
My Chart

Preferred Contact Time:

Health Insurance?: Yes
No

If Yes, Please Specify the Name of Your Insurance:

Service you are Requesting

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 Health
Hair Removal/ Esthetician
Voice Therapy
Other Needs (Fill in the blank)

Reason For Requested Visit: