New Patient Information
This form helps us get to know you and prepare for your care. Please have your photo ID and insurance card ready to upload. It should take about 5–10 minutes to complete. Required fields are marked with a red asterisk (*). Let’s get started!
CONTACT INFORMATION
Enter your email
*
example@example.com
Enter your Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Enter your phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your preferred contact method? (Select all that apply)
*
Phone Call
Text
Email
I consent to receive phone calls from the Crane Center for purposes related to my care and services.
*
Yes
I consent to receive text messages from the Crane Center for purposes related to my care and services.
*
Yes
PERSONAL DETAILS
Enter your Full Legal Name
*
First Name
Last Name
Enter your Preferred First Name if different from your Legal Name
Select your Pronouns
*
he/him
she/her
they/them
Enter Date of Birth (DOB)
*
-
Month
-
Day
Year
Date
Enter your Assigned Sex at Birth
*
Male
Female
Enter your Gender Identity
*
Male
Female
Trans-Masculine
Trans-Feminine
Gender non-conforming
What is your preferred language for consultation?
*
English
Spanish
Chinese
Other
Do you require an interpreter for your consultation?
*
Yes
No
INSURANCE AND IDENTIFICATION
Do you have insurance?
*
Yes
No insurance, I will Self Pay for Services
Primary Insurance Name
*
Policy Holder
*
Self
Other
Policy Holder Name
*
Policy Holder Date of Birth (DOB)
*
-
Month
-
Day
Year
Date
Policy Holder's Gender Identity
*
Male
Female
Your Relationship to Policy Holder (Primary Insurance)
*
Child
Mother
Father
Spouse
Member Identification Number
*
Upload Front of Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Back of Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a secondary insurance?
*
Yes
No
Secondary Insurance Name
*
Policy Holder
*
Self
Other
Policy Holder Name
*
Policy Holder Date of Birth (DOB)
*
-
Month
-
Day
Year
Date
Policy Holder's Gender Identity
*
Male
Female
Your Relationship to Policy Holder (Secondary Insurance)
*
Child
Mother
Father
Spouse
Member Identification Number
*
Upload Front of Secondary Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Back of Secondary Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are you currently enrolled in any of the following?
*
Medicare
Tricare
Medi-Cal
Medicaid
COBRA
OHIP
None
Upload Front of Identification or Driver's License
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Back of Identification or Driver's License
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
APPOINTMENT AND PROCEDURE
Which type of initial consult appointment type would you prefer?
*
In Office Consult
Virtual Consult
Which location are you interested in getting services at? (Top Choice)
*
San Francisco, California
Boulder, Colorado
Austin, Texas
Which procedure are you most interested in? (if you are interested in multiple procedures, please let the Patient Intake Specialist know upon initial contact)
*
Double Incision
Keyhole
Body Masculinization
Body Feminization
Facial Masculinization
Facial Feminization
Breast Augmentation
Metoidioplasty
Phalloplasty
Urethroplasty
Scrotoplasty
Testicular implants
Glansplasty
Penile Inversion Vaginoplasty
Peritoneal Flap Vaginoplasty
Vulvoplasty
Gender Nullification
Female to Male Revision
Male to Female Revision
Comments/Questions/Scheduling Preferences (Optional)
YOUR CONNECTION TO OUR PRACTICE
How did you hear about us?
*
Word of Mouth
Pride Event
Primary Care Physician
Advertising/Social Media
TransHealthCare
Specialist Physician
Hospital
Insurance Company
Specific Physician Who Referred You
*
Promo Code (Optional)
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