Preferred Name *

First Name

Last Name

Legal Name

*If different than preferred name

First Name

Last Name

Birth Date *

MM

DD

YYYY

Preferred Appointment Day(s) / Time(s) *

Anytime, any day!

Weekdays 8am - 2:30pm

Weekdays 3pm or later

Weekends 8am - 2:30pm

Weekends 3pm or later

Do you have a preferred provider? *

If you have no preference, we'll match you based on your schedule and treatment needs.

No

Yes

Do you plan to bill health insurance for your electrolysis treatments? *

Providers can supply a receipt (Superbill) for you to submit directly to your insurance for possible reimbursement. You will need to be pre-authorized by your insurance to receive reimbursement. Once you've connected with a provider and had a Phone Consultation, you will contact your insurance company and primary care physician for the referral to that provider. If you are with Kaiser, contact Gender Pathways.

Yes

No