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Patient recommendation
This form is for transgender patients to recommend their healthcare provider to be added to our database at
https://genderminorities.com/find-transgender-info-services/medical-surgical/
If you are a healthcare provider and wish to register your practice, please use this form instead
https://docs.google.com/forms/d/e/1FAIpQLScidRGcivu3brbdIt-qQNOILkq5at6L89F1HDpI9VDw9hlRKA/viewform
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* Indicates required question
1. Name of provider or practice
*
Your answer
2. Provider website
Your answer
3. Provider phone
Your answer
4. Provider email
Your answer
5. In which region is the healthcare provider located?
*
Northland
Auckland
Waikato
Bay of Plenty
Gisborne
Hawkes Bay
Manawatu - Whanganui
Taranaki
Wellington
Tasman
Nelson
Marlborough
West Coast
Canterbury
Otago
Southland
Other
Required
6. Category or categories:
GP
Endocrinologist
Mental health
Sexual and/or reproductive health
Child and youth services
Pregnancy and birth
Voice therapy
Permanent hair removal
Alternative therapies
Other:
7. Is there anything you would like to tell us about your recommendation?
Your answer
8. Can we publish your comments from question 7? For example, in our reports or funding applications. If you have written anything that would identify yourself or others, we would remove the identifying details.
Yes
No
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