HRT Review Form

This form is only for patients who have already been prescribed HRT for menopause symptoms, are happy with it and would like to re-order it.

You'll need a recent blood pressure reading to complete this form - you can use a home monitoring machine.

A clinician will review your form and - if safe to do so - will re-prescribe your HRT medication for 6 months (normally it will be up to 12 months but temporarily reduced due to current HRT supply issues). We'll send you a text to let you know.  Your HRT will then be available for collection in a few days at your nominated pharmacy or from reception.  You'll then need to complete this review form every time you'd like us to re-prescribe HRT.

If after reviewing your form we need to have a further discussion with you before re-prescribing your HRT, we'll text you to ask you to book a GP appointment.

 

 

Last Updated: 04/12/2023

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • HRT Review

    This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
    Smoking Status
    Have you ever had a blood clot, stroke, heart diseas, or major illness?
    Since your last HRT review have you experienced any unexpecte bleeding? Including: bleeding after sex; bleeding between your periods; or (if your periods have stopped) any bleeding more than 12 months after your last period.

  • Blood Pressure

    If you are not able to find a way of measuring your blood pressure in the community, please contact the surgery and arrange an appointment with one of the CTAC nurses.     

    If you on HRT which contains Estrogen a blood pressure is a requirement to ensure safe prescribing of this medication

  • Please take some time to read the information in the links below regarding the risks and benefits of HRT

     

    Each link will open in a new tab or window to allow you to come back to this form to continue.

     

    Please confirm you have read about and understand the risks and benefits of taking HRT. (optional)

  • Comments

  • Text Messaging

    We may text you after reviewing your HRT form and will use the mobile number on your patient record. If we don't have a mobile number for you (or you've recently changed mobile number) please fill in our change of contact details form.

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