Transgender Hormone Therapy Intake Form
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Transgender Hormone Therapy Intake Form
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This specialized intake form is designed for healthcare providers offering gender-affirming hormone therapy to transgender and non-binary patients. It captures essential information including chosen name and pronouns, gender identity timeline, dysphoria symptoms, previous gender-affirming treatments, mental health support system, and comprehensive medical history relevant to hormone safety. The form includes informed consent elements specific to masculinizing or feminizing hormone therapy risks and expected outcomes.
The template streamlines the intake process for endocrinologists, primary care providers, and specialized gender clinics following informed consent or WPATH standards of care models. It documents contraindications, baseline vital signs, fertility preservation discussions, and support system assessment. The form helps providers ensure patients understand treatment expectations while collecting all necessary clinical data for safe hormone prescription and ongoing monitoring throughout transition care.
What's included
- Chosen name and pronouns
- Gender identity and dysphoria history
- Hormone therapy goal selection
- Mental health assessment
- Previous gender-affirming treatments
- Fertility preservation discussion
- Cardiovascular risk factors
- Informed consent documentation
- Support system evaluation
- Contraindication screening
Who uses this template
- Gender-affirming care clinics
- Endocrinology practices
- LGBTQ health centers
- Primary care providers
- Transgender health specialists
All form fields
9 fields across 3 pages. Customize any field after signing up.
How to use the Transgender Hormone Therapy Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Transgender Hormone Therapy Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Transgender Hormone Therapy Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 18 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Transgender Hormone Therapy Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Transgender Hormone Therapy Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 18 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Transgender Hormone Therapy Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Transgender Hormone Therapy Intake Form for your practice. Set up in minutes.
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