HRT Request - Wandsworth Medical Centre

HRT Request Form

If you would like to make a HRT request, please use this form.

If you would like to read about the menopause and hormone replacement therapy, please visit:

www.womens-health-concern.org
www.menopausematters.co.uk
www.menopausecafe.net
www.daisynetwork.org (for premature menopause)
www.queermenopause.com/resources (for people who identify as LGBT+)

HRT Request Form

Required fields are indicated by *

Are you completing this form on behalf of:

YourselfSomeone else

About you

First Name(s)*
Name(s) as it appears on the patient's passport.

Last Name*
Name(s) as it appears on the patient's passport.

Postcode*
The one used to register with your GP.

Your Date of Birth*
Your date of birth is used to verify your identity

Sex*
MaleFemaleOther
As on your medical record.

Phone Number*
This phone number will be used for all correspondence relating to this request.

Email*
This email address will be used for all correspondence relating to this request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

About the patient

First Name*
As it appears on the patient's passport

Last Name*
As it appears on the patient's passport

Postcode*
The one registered with the patient's GP

Your Date of Birth*
Patient's date of birth is used to verify your identity

Sex*
MaleFemaleOther
As on the patient's medical record.

About you

First Name*

Last Name*

Your Date of Birth*
Your date of birth is used to verify your identity

Sex*
MaleFemaleOther
As on your medical record.

Phone Number*
This phone number will be used for all correspondence relating to this request.

Please continue completing the form below

Address (including postcode):

Are you currently using hormone replacement therapy?*
YESNO

What is the name of your HRT and what is the dose?*

Is this review your 3 month medication review after starting HRT or is this your annual review?*
3 MonthAnnual

Is HRT helping you?*
YESNO

Are you happy to continue taking your HRT at your current prescribed dose or would you like to speak to a doctor?*
YESNO

Are you getting any side effects?*
YESNO

What is / are the reasons you wanted to start HRT?
Hot flushesVaginal drynessNight sweatsMood changeFeeling anxiousPoor sleepPoor concentration

If you answer 'yes' to any of the following questions, please book an appointment in the same week.

If your periods stopped a year ago, have you noticed any irregular bleeding?
YESNO

If you have been on HRT longer than 3 months, have you noticed any irregular bleeding?
YESNO

Do you have any bleeding after sex?
YESNO

Have you noticed any breast lumps?
YESNO

When was your last period?*

Do you have a uterus?*
YESNO

Do you have a Mirena coil fitted?*
YESNO

When was your Mirena coild fitted?

Are you having sex?*
YESNO

Are you using contraception?*
YESNO

Please tick which statement below applies to you and that you understand it:*
If you are aged under 55 years, you may require contraception.If you are aged over 50 years and your last period was under 1 year ago, you may require contraception as there is a risk of pregnancy.If you are aged under 50 years and your last period was under 2 years ago, you may require contraception as there is a risk of pregnancy.

Please book an appointment if you would like to discuss contraception.

Blood pressure reading:*
Please use the blood pressure machine in the reception area or visit a local pharmacy

Date blood pressure taken:*

What is your weight*
A scale is available in the reception area

What is your height*
A height measuring station is available in the reception area

When was your last cervical smear test?*
If you are over age 25 you should have had a cervical smear test. If you have had a smear test, but it was more than 3 years ago, please book an appointment with the practice nurse for a repeat test.

When was your last mammogram?*

Please read the following leaflet.
HRT and Breast Cancer Risk Information

Confirmation you have read HRT information leaflet:
I confirm I have read the leaflet regarding HRT and breast cancer risk

Confirmation
I confirm that the information provided is accurate to the best of my knowledge

Monday	08:00-18:30
Tuesday	08:00-20:00
Wednesday	08:00-20:00
Thursday	08:00-18:30
Friday	08:00-18:30
Saturday	09:00-13:00/16:00*subject to availability
Sunday	Closed

HRT Request Form

HRT Request Form

Opening Hours