Repeat Prescribing of Hormone Replacement Therapy (HRT) Request

This form is for ANNUAL HRT reviews only. Outwith this annual review, you can request your repeat HRT via the normal repeat prescription pathway.

Before you start to fill in this form, please be aware that this is a form for renewal of an HRT prescription that you have already been started on by a doctor. If you wish to start HRT, please phone reception and request a triage appointment with a doctor to discuss.

You will need an up to date blood pressure reading before you complete the online details. This can be a home blood pressure reading or attend the practice where we have a BP Pod that you can use without an appointment. Please record the two numbers given, for e.g. 120/80

General information

Alternatives to HRT

HRT
Please use format day/month/year e.g. 12/05/1979
Enter Email

Your Height and Weight

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

HRT Review

e.g. 120/70
Please use format day/month/year e.g. 12/05/1979
Have you had a hysterectomy (operation to remove your womb)? *
Do you have a coil fitted that releases hormones (e.g. Mirena)? *
Are you happy with your current HRT prescription? *
Have you experienced new bleeding or a change in bleeding since your last review? *
Have you experienced any side effects? *
Have you ever been diagnosed with a clot in the leg (DVT) or lung (PE)? *
Have you ever been diagnosed with breast cancer? *
Have you ever been diagnosed with ovarian cancer? *
Have you ever been diagnosed with a stroke or a mini stroke?
Have you ever been diagnosed with liver disease?
Do you suffer from migraines?
Do you smoke?
Do you take any weight loss injections either through NHS or privately?
Has a close family member (parents, siblings or children) ever been diagnosed with a clot in the leg (DVT) or lung (PE), breast cancer, ovarian cancer, stroke, mini stroke or liver disease?

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.