Repeat Prescribing of Hormone Replacement Therapy (HRT) Request

Full Name

Email address

Please double check you’ve entered the correct email address.

Contact number

Name of HRT & Dose

Date Started HRT/Length of time taking HRT

Home Blood Pressure (Result & Date)

Systolic (top number)

Diastolic (bottom number)

Home Blood Pressure:- 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

Weight in kg (Result & Date)

Height in cm (Result & Date)

If you have answered 'YES' to any of the questions, please give details.

Declaration

I understand that HRT has certain risks associated with its use. More information on the risks and alternatives, please visit this site www.menopausematters.co.uk/risks.

***Please report any irregular vaginal bleeding, calf pain or swelling, sharp chest pain, shortness of breath or coughing up blood.

***Please inform a health care professional if you are having an operation scheduled or a period of immobilisation e.g. leg in plaster.

*** HRT does not offer you contraceptive protection, unless you have the hormonal coil (Mirena). If you believe you require contraception, then please call to discuss this separately with a GP.

The information provided is correct to the best of my knowledge.