The following form has been designed by our clinicians, to help us understand your needs, please read the following before proceeding to complete the form.

  • Please do not complete this if you have not had HRT before, call us to book an appointment to discuss with a GP.
  • If you have recently completed this form and had a prescription, your HRT has probably been added to your repeat prescription and can be requested (unless there were issues with your treatment), please try this option before completing this form.
  • This form is part of the review process of your medication. The information you add will be added to your notes and sent back to you by email to check. Please use an appropriate email address and make sure the form is completed fully and accurately.
  • If you have bleeding that you are worried about, please book a face to face consultation with a GP.

The questionnaire provides an in depth analysis of your requirements, which will be reviewed by one of our subject specialists, with the aim of providing you with the most appropriate care.

Please answer honestly and concisely, completing all the questions relevant to you. Failure to complete the form to a satisfactory standard will delay your treatment, as you will be contacted for further information or to complete the form again.

  • Please allow 10 working days (Mon – Fri, excluding Bank Holidays) for your submission to be reviewed. You will then be contacted to discuss the next step in your treatment.

If you are concerned that you have not heard from us after 10 working days, please contact us on 01685 700404

Personal Details

Please provide your personal details below so we can identify you on our system.

Step 2: Details of Request

Step 3: Health Assessment

Step 4: Contraception

Step 5: Finish and Confirm