Repeat HRT Request Form-My Specialist GP

Repeat HRT Request Form

This form can be used if you have had a Consultation with us in the last 12 months, otherwise, a Consultation will be required. At My Specialist GP we are passionate about trying to help improve women's experience of hormonal changes and challenges and life after the menopause. We have a policy for having an annual review with all our patients to ensure their care is appropriate and suits them. This is in line with national guidance. We may be forced to decline to prescribe if you have not had an annual review or annual blood test for your testosterone level.

Full Name

Phone Number

Date of birth

What are your current HRT medications?

What HRT medications are you requesting?

Any other medications being requested? Y/N

Do you have a Mirena coil – if YES, please include the date of fitting

If you are menopausal are you bleeding ? YES / NO

are you having unexpected bleeding if you are perimenopausal? YES / NO

Do you know your current blood pressure?

Do you feel your HRT is suiting you or do you feel it could be optimised?

If you feel your HRT could be optimised, please complete a Menopause Symptom Questionnaire and book a review with Dr Ashby or Dr Dasgupta.