New Patient Information

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

CityState

Zip Code
Enter your phone number*
Please enter a valid phone number.
What is your preferred contact method? (Select all that apply)*

Phone CallTextEmail
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 NameLast Name
Enter your Preferred First Name if different from your Legal Name
Select your Pronouns*

he/himshe/herthey/them
Enter Date of Birth (DOB)*

MonthDayYear
Date
Enter your Assigned Sex at Birth*

MaleFemale
Enter your Gender Identity*

MaleFemaleTrans-MasculineTrans-FeminineGender non-conforming
What is your preferred language for consultation?*

EnglishSpanishChineseOther
Do you require an interpreter for your consultation?*

YesNo
INSURANCE AND IDENTIFICATION
Do you have insurance?*

YesNo insurance, I will Self Pay for Services
Primary Insurance Name*
Policy Holder*

SelfOther
Policy Holder Name*
Policy Holder Date of Birth (DOB)*

MonthDayYear
Date
Policy Holder's Gender Identity*

MaleFemale
Your Relationship to Policy Holder (Primary Insurance)*

ChildMotherFatherSpouse
Member Identification Number*
Upload Front of Insurance Card*

Cancelof
Upload Back of Insurance Card*

Cancelof
Do you have a secondary insurance?*

YesNo
Secondary Insurance Name*
Policy Holder*

SelfOther
Policy Holder Name*
Policy Holder Date of Birth (DOB)*

MonthDayYear
Date
Policy Holder's Gender Identity*

MaleFemale
Your Relationship to Policy Holder (Secondary Insurance)*

ChildMotherFatherSpouse
Member Identification Number*
Upload Front of Secondary Insurance Card*

Cancelof
Upload Back of Secondary Insurance Card*

Cancelof
Are you currently enrolled in any of the following?*

MedicareTricareMedi-CalMedicaidCOBRAOHIPNone
Upload Front of Identification or Driver's License*

Cancelof
Upload Back of Identification or Driver's License*

Cancelof
APPOINTMENT AND PROCEDURE
Which type of initial consult appointment type would you prefer?*

In Office ConsultVirtual Consult
Which location are you interested in getting services at? (select a max of 2)*

San Francisco, CaliforniaBoulder, ColoradoAustin, 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 IncisionKeyholeBody MasculinizationBody FeminizationFacial MasculinizationFacial FeminizationBreast AugmentationMetoidioplastyPhalloplastyUrethroplastyScrotoplastyTesticular implantsGlansplastyPenile Inversion VaginoplastyPeritoneal Flap VaginoplastyVulvoplastyGender NullificationFemale to Male RevisionMale to Female Revision
Comments/Questions/Scheduling Preferences (Optional)
YOUR CONNECTION TO OUR PRACTICE
How did you hear about us?*

Word of MouthPride EventPrimary Care PhysicianAdvertising/Social MediaTransHealthCareSpecialist PhysicianPatient in the PracticeHospitalInsurance CompanyOther
Specific Physician Who Referred You*
Promo Code (Optional)
Should be Empty:

New Patient Information

CONTACT INFORMATION

PERSONAL DETAILS

INSURANCE AND IDENTIFICATION

APPOINTMENT AND PROCEDURE

YOUR CONNECTION TO OUR PRACTICE