HRT Review Form

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 will need a recent blood pressure reading to complete this form. You can use your own BP machine if you wish.

A clinician will review your form and, if safe to do so, will re-prescribe your HRT medication for up to 12 months. Your HRT will then be available for collection in a few days at your nominated pharmacy.  

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.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • HRT REVIEW

    This form collects your 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.

    Please read our Privacy Policy to discover how we protect and manage your submitted data.

    I consent to the practice collecting and storing my data from this form.
    Are you currently prescribed Mounjaro (Tirzepatide) or Wegovy (Semaglutide) privately for weight loss? (optional)
    Smoking status
    Have you ever had a blood clot, stroke, heart disease, breast or gynaecological cancer?
    Do you suffer migraines
    Since your last HRT review have you experienced any unexpected bleeding? (Bleeding after sex, bleeding in between your periods, or if your periods have stopped- bleeding more than 12 months after your last period.)

  • BLOOD PRESSURE

    Date of Blood pressure
    For example, 15 3 1984

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

    NHS FORM - HRT

     

    BENEFITS AND RISKS OF HRT

    Please confirm you have read about and understand the risks and benefits of taking HRT
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Page last reviewed: 02 February 2026
Page created: 20 January 2026