HRT Review

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Please use this form to request a repeat prescription of your HRT.

If you would like to discuss starting HRT you will need to consult with a GP first

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Personal Details

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HRT Review Questions

Have you had a hysterectomy (operation to remove your womb): *

Do you have a coil that releases hormones fitted (eg Mirena): *

Are you happy with your current HRT prescription: *

Can you provide us with a recent blood pressure reading (we accept blood pressure readings taken at home: *

Have you experienced any new bleeding or change in bleeding pattern since your last HRT review: *

Have you or a close family member (parents, siblings or children) ever been diagnosed with a clot in the leg (DVT) or lungs (PE): *

Have you ever been diagnosed with breast or ovarian cancer: *

Have you ever been diagnosed with a stroke or mini-stroke (TIA): *

Have you been diagnosed with liver disease: *

HRT is associated with an increased risk of certain conditions including clots, breast cancer and ovarian cancer. It is important you remain aware of these risks as well as the benefits of HRT.

MORE INFORMATION ON THE RISKS AND ALTERNATIVES

Please remember that HRT is not a form of contraception and you will require additional contraception unless you are:

Aged 50 or over AND have not a period in over a year
Aged <50 AND have not a period in over two years
Aged 55 or over

Do you need to discuss additional contraception: *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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HRT Review

Please use this form to request a repeat prescription of your HRT.

Privacy Consent

HARBOURS MEDICAL PRACTICE

FORTHVIEW ROAD SURGERY

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