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HRT Review Form

This form is for women already established on HRT.  To ensure patient safety, please complete all questions. Please note we cannot process prescription requests without an up to date height, weight and blood pressure – this is for patient safety reasons. Once your prescription has been processed, a 12 month supply of your medication will be issued – please ensure you collect the total balance from the pharmacy.

Please read information on blood clots.

If a prescription is not issued we will contact you to let you know.

HRT Review
Please use format day/month/year e.g. 12/05/1979
Do you want to continue on this medication?
Have you had any side effects from your medication that you wish to discuss?
Do you currently have a Mirena coil in place?
Please be aware that a Mirena coil expires after 5 years and cannot be used as part of your HRT after this. If your coil expires or you have it removed, please contact the surgery to discuss
Are you currently using contraception?
Do you have any vaginal discomfort or dryness?
Have you had any bleeding after sex?
If applicable, is your cervical screening up to date?
If applicable, is your breast screening up to date?
Have you noticed any breast lumps?
Please indicate if you have previously had or currently have any of the following
Do you currently smoke?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.