Transgender Medical Emergency Consent Form

Full Name

Home Address

Phone Number

Age

Date of Birth

Social Security Number:

Are you seeking medical care for a transgender related condition?

If yes, please describe your condition:

Have you seen a doctor for this condition before?

Name of Doctor

Phone Number

Hospital Address

Are you currently taking any hormones or other medications for your condition?

If yes, please list the medication(s) and dosages:

Do you have any allergies?

If yes, please list the allergies and reactions:

Is there anything else we should know about your medical history?

I understand that I am seeking medical care for a transgender related condition.

I hereby give my consent for the medical staff at the facility to provide me with the care that I am seeking. I understand that this may include, but is not limited to, hormone therapy, psychological counseling, and/or surgery.

Date