DRAFT

Consent for Transgendered Patients Continuing Hormones

1. I have informed my provider that I have been taking hormones for gender transition for ___________ (# of months or years).
2. I agree to complete the full informed consent form within the next 30 days.
3. I agree to complete all lab work, or other tests that my provider may order, within the next thirty days.
4. I understand that, until I complete the labs and the informed consent, my provider will only write me a prescription for 30 days worth of hormones.

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Patient Signature Date

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Medical Provider Signature Date