Gender-Affirming First Visit Packet

Thank you for choosing Virginia Mason Franciscan Health for your medical care; we are honored you have chosen us. To help ensure we can review all of your medical information, please submit this online form and include all of the elements in the First Visit Packet information. Upon receipt of all elements at one time, we will contact you to schedule. Please note that we cannot retain individual pieces of patient health information.

PATIENT INFORMATION

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Note: While Virginia Mason Franciscan Health recognizes a number of genders, many insurance companies and legal entities unfortunately do not. Please be aware that the name and sex on your insurance card must be used on documents pertaining to insurance and billing.
Your insurance company may require an insurance authorized referral prior to seeing a specialist. Not all health plans require this - please check your insurance plan to determine if you need an insurance approved authorization prior to your office visit. Without this, you may pay more or care may not be covered. Please call the number on your health plan ID card and ask if you need an insurance approved authorization to see a Plastic and Reconstructive surgeon in consultation for your desired surgery.

Please attach supporting documentation in PDF format only

(include all elements from the First Visit Packet sheet at one time)

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