Request a Teleconsultation

Teleconsultation Request
1. Please complete the information required below.
2. If you have already sent in your medical information you will not need to submit again. Please indicate YES, please use my existing information and advance to the last page, and submit.
3. Your Destination Manager will confirm timing and surgeon availability in advance of the session.
4. If the dates are not available, alternate dates will be provided.
5. All teleconsultation instructions and access will be provided at least 48 hours prior to your session. Please ensure you notify us with 24 to 48 hours of your scheduled session if you are unable to attend and we will reschedule.
Lead Source
Have you completed a medical form prior?

Yes, please use my existing information No, I will complete the attached
Requested Teleconsultation Date

Month Day Year
Date
Requested Start Time

: Hour Minutes AM/PM Option
End Time

: Hour Minutes AM/PM Option
Duration
Sessions are in 15 minute increments. 15, 30, 45 and 60 minutes
Indicate Your Time Zone

Surgery Details

Please tell us the procedures you are interested in
Preferred Destination *
If destination not listed, please indicate
Preferred Hospital or Clinic (If Known)
If hospital not listed, please indicate
Do you have a preferred surgeon?
Is this for gender transition surgery?

No Yes
How long have you been on hormone therapy?
Can you provide a referral letter from your psychologist, sex therapist or psychiatrist

No Yes
If yes, please upload your referral letter

Browse Files

Cancel of
Treatment Category
Requested Procedure(s) *
Requested Procedure(s)
Requested Procedure(s)
If not mentioned above please add treatments
What are Your Personal Goals for having Surgery
Anything you want to ask or tell the surgeon?
When are you planning to have your surgery done ?
Arrival Date

Month Day Year
Date
Requested Date of surgery

Month Day Year
Date

Teleconsultation Request