In order to reserve a date for your surgery please fill out the form below in it's entirety. A copy of this form is also available in PDF Format if you prefer to fill it out manually to mail in. Make sure you meet the Requirements and follow any instructions to complete this reservations as indicated. If you have any questions about this procedure please feel free to call us directly and a representative will be happy to assist you with the process.

Fara Movagharnia, DO, FACOS
Founder of Center for Gender Reassignment Surgery
200 Galleria Parkway, Suite # 590
Atlanta, GA. 30339
Tel: 770-951-7595   Fax: 770-951-7598
Dr. Movagharnia's cell phone: 404-556-8747 (after hours & weekends only)
E-mail: Info@GRSAtlanta.com

Legal Name		Address
Telephone		E-mail
Birth Date		Height
Weight		HIV Status
Smoker	YES NO
I would like to plan pre-operative consultation prior to my surgery date.
I have concerns about vaginal depth and may require skin graft
Criteria for surgery: Weight less than 210 lbs and non smoker, due to increased risks of healing and complications associated with smoking.  If you do not meet these criteria, you cannot have surgery. Legal name is required only for Surgical Declaration Letter, which is used to certify permanent and irrevocable GRS/SRS for passport, birth certificate and legal ID where required.  The letter will indicate NEW Name (legal name) if appropriate.
Date Hormone Therapy Started		Endocrinologist / Physician Name
Physician Number		Real Life Test Started
# 1 Letter of Recommendation by - Name		# 2 Letter of Recommendation by - Name
Telephone of Recomendation # 1		Telephone of Recomendation # 2
Employer		Emergency Contact
Do you have a target date or time frame for your surgery?
All patients must meet the requirements set by the HBIGDA Standards of Care. We understand that you may not have arranged for LETTERS of RECOMMENDATION at the time this application is made.  If you know the professionals who you expect to refer you, please identify them which will permit us to contact them if we do not receive these prior to your surgery.
Please enclose: $1000.00 non-refundable down-payment to reserve a date. A photograph so we can identify you when you show up for surgery. HIV Status (performed within 12 weeks of surgery).