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 BP monitor is available in our main waiting room for patients who aren’t able to get 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 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.

HRT Review
Are you happy to continue with your HRT?
If you’re not happy with your current HRT, please call the Practice on 0300 790 6266 to book a GP review appointment from 8am Monday-Friday. Please don’t complete and submit this form.
Please use format day/month/year e.g. 12/05/1979

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

This can be done with your own BP monitor you have at home. There’s also BP monitor available for patients to use in our main waiting room.
Do you smoke?
Have you ever had a blood clot, stroke, heart disease, cancer, or other major illness?
Do you have migraines?
Since your last HRT review have you experienced any unexpected bleeding?
Including: bleeding after sex; bleeding in between your periods; or (if your periods have stopped) any bleeding more than 12 months after your last period.
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.
0 of 200 max characters

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.
www.theriversidepractice.co.uk/information-for-patients/update-your-personal-details

Privacy Policy

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.