Application for Services

Seattle Transgender Help Network

We are committed to serving the Transgender Community

Application for Essential Health Care.

* Required field
Program Registration.

First name:* _______________________ .

Last name:* _______________________ .

Address:* _________________________ .

Apt/Suite:* __________ .

City:* _____________________________ .

State:* ____________________________ .

Zip code:* ___________.

Ph:* (_______) _________-___________ .

Fax: (_______) _________-___________ .

E-mail:* __________________________ .

Specifically how may we help? ______________________________________________________________________________

______________________________________________________________________________

Health Care Facilities Name:* _______________________________________________________

Address:* ________________________Suite:* _____ , City:* ____________ , Zip:* 98_______

Medical Health Professional name:* __________________________ ,

Mental Health Professional name: *___________________________ .

Ph:* (______)________-____________ .

Fax:* (_____)________-____________.

If applying for medication assistance please provide the following.

Medication:* _____________________ ,

Pharmacy:* ______________________ ,

Ph:* (______)________-____________ .

Fax:* (_____)________-____________.

Please copy & paste this page in your e-mail.

If you have any questions please send your inquiries to: Info@SeattleTransgender.org

Security of Your Personal Information

Seattle Transgender Help Network is committed to protecting the security of your personal information. We use a variety of security technologies and procedures to help protect your personal information from unauthorized access, use, or disclosure. For example, we store the personal information you provide on computer systems with limited access, which are located in controlled facilities. When we transmit highly confidential information (such as a credit card number or password) over the Internet, we protect it through the use of encryption, such as the Secure Socket Layer (SSL) protocol.

Last modified March 21, 2007

Welcome to Seattle Transgender

Committed to serving the Transgender Community