Request an Updated Surgery Letter of Referral

If you've already had an appointment with a Rebel Heart Therapy clinician for a gender-affirming surgery referral letter and have received it but now require an updated version for your surgeon, you can request it here. We aim to make this process seamless to ensure you have the support you need for your surgery.

Directions:

Please complete the form below, providing all necessary information. Our staff will verify the details included in your existing letter and proceed to generate an updated version. If additional information is required or we need to clarify any details, we'll contact you promptly.

Timeframe:

You can expect to receive the updated letter or be contacted for any necessary clarifications within two weeks from the date of your form submission.

Name

As it appears on the existing referral letter

First Name

Last Name

Email

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Date of Original Appointment

Approximate Date of the Initial Appointment with Rebel Heart Therapy Clinician

MM

DD

YYYY

Clinician's Name

Which Rebel Heart Therapy clinician wrote your original letter?

Name of Surgeon Requesting Updated Letter

Name of Surgeon or Facility

Reason for Requesting an Updated Letter

Additional Information

Please provide any additional information you want us to know.