HRT REQUEST FORM

HRT Prescription Request Form
PLEASE TAKE TIME TO FILL THIS CAREFULLY

* Indicates required field

Name Address Date of Birth *

Contact Number *

Nominated Chemist *

HRT Exact name, dose, and prescription details *

I CONFIRM I HAVE GIVEN EXACT NAME DOSE AND PRESCRIPTION DETAILS IN ANSWER TO THE QUESTION ABOVE *

YES

When was your last HRT check, a HRT check involves seeing the doctor in person *

Do you still have periods? when was last one *

Do you have a womb (uterus) have you had a hysterectomy? *

Do you have a Mirena Coil (or any progesterone implant) and what was the date of insertion *

Do you go to or have you been to any HRT or menopause hubs or clinics *

Approximate weight (kg) *

Do you smoke? *

Have you ever had a blood clot ? *

Have you ever had breast, womb, or ovarian cancer? *

Family breast cancer under age 50? *

Parents or siblings with heart disease or stroke under 45? *

Liver disease or unexplained vaginal bleeding? *

Date of last smear? *

Date of last mammogram or breastcheck *

Have you ever had a dexa scan? (bone density) *

“I confirm the information provided is accurate to the best of my knowledge and understand a clinician may need to contact me before a prescription is issued.” *

Yes

Submit

HRT Prescription Request FormPLEASE TAKE TIME TO FILL THIS CAREFULLY

HRT Prescription Request Form
PLEASE TAKE TIME TO FILL THIS CAREFULLY