Community Health Care | Where Care is the final word
1047753048000 CHC Hilltop Medical Clinic1202 Martin Luther King Jr. WayTacoma, WA 98405-3926Phone: (253) 441-4742Fax: (253) 442-8790_December 6, 2019Re: Preferred name (Legal name) Last nameDOB: 00/00/0000Preferred pronouns: She/HerTo whom it may concern: I am writing on behalf of the abovementioned patient whom I would like to refer for gender affirming breast augmentation. This patient has been in my practice at Community Health Care for x years. I have independently confirmed their diagnosis of Gender Dysphoria (ICD-10 F64.1) per DSM 5 criteria (via record review or initiation of HT). The patient has been publically and consistently living in a gender role congruent with their affirmed gender for over x years. Social transition is evidenced by the patient’s use of traditionally female dress. They have been consistently on hormone therapy for over x years. While these interventions have reduced dysphoria, the patient continues to report significant distress due to the body not aligning with their gender identity. The patient has expressed a consistent desire for surgical affirmation. Surgery will address their gender dysphoria by enabling them to pass as female in general society.Breast augmentation is the next step to enable the patient to continue living in the gender role in which they most comfortably and effectively function. The patient has demonstrated an understanding of the permanence, costs, recovery time, and possible complications of this surgery and is fully capable of providing informed consent. The patient is reasonably expected to follow pre and post-surgical treatment recommendations responsibly. It is my opinion that name is emotionally and practically ready for this surgery provided you find them medically fit. It you would like to discuss this in more detail, please contact our clinic at (253) 722-1720. Sincerely,Provider nameWA License #ABC12345 ................
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