Contact — NV Gender Clinic

Join our referral network.

Please complete all required fields.

Public fields noted with an asterisk (*) will be shared on the NV Gender Clinic website.

All other fields will be private, not posted on the website, and used for administrative use for the NV Gender Clinic.

Click here for an example of how your information will be posted on the website:

Below is an example of how your information will be posted on the website:

Name

First Name

Last Name

Pronouns (*)

Patient Contact Email (*)

Provider Contact Email (will not be posted on website)

Office Phone

(###)

###

####

Office Address

If you do not have a physical location please indicate that, and where you are based from (City & State)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Name

Business Website

http://

Your Credentials

Your Discipline/Specialty

Are you a member of the BIPOC community?

Are you a member of the gender diverse community?

Does your office have a discreet entrance/exit for patient privacy?

Do you provide letters of recommendation for patients in support of gender affirming care?

(Letters required by insurance and/or surgeons for hormones and surgeries)

How did you hear about the NV Gender Clinic?

Do you know other people who are affiliated with the NV Gender Clinic?

Please list any feedback or suggestions for us

Are you interested in further training or professional development on working with the gender diverse community?

Are you interested in learning more about the Gender-Affirming Care Consultation Group?

This is a multi-disciplinary group organized by Vic Campbell, Mary Minten, and Sage Rian. More info on the Professional Consultation page (within Resources).

Do you consent to having the above information listed on a gender diverse healthcare resource website for patients and providers? If so, enter your name below.

Entering your name here is your electronic signature and indicates that you agree to being listed on our provider/resource database.