HRT Screening Form

What is your name? *

What is your date of birth? *

What is your mobile telephone number? *

Please type in your HRT regime *

Please type in the HRT medication you are requesting *

Are you taking HRT from any other source/clinic? *

Yes No

Please type in which chemist you want the prescription to be sent to, or indicate if you want to collect it from the surgery. *

CLINICAL RISKS AND BENEFITS OF HRT

The benefits of HRT usually outweigh the risks with recent evidence showing that the risks of serious side effects from HRT are very low.

The risks and benefits are documented on the NHS website - please click here for more information, which was updated in February 2023 with a review due in February 2026. Further information about the risks and benefits are documented on the NHS Inform - please click here for more information.

Please be reminded that HRT is not a replacement for contraception.

We would be grateful if you could read this information to make an informed decision on continuing HRT.

I HAVE READ AND UNDERSTAND THE INFORMATION GIVEN ABOVE. (If you tick no and do not understand this information, then you will get a call from our receptionist to make a clinician appointment) *

Yes No

I WISH TO CONTINUE WITH HRT (YES/NO). (If you tick no, then you will get a call from our receptionist to make a clinician appointment.) *

Yes No

I WISH TO HAVE A DISCUSSION ABOUT MY HRT WITH A CLINICIAN FURTHER. (If you tick yes, then you will get a call from our receptionist to make a clinician appointment) *

Yes No

CLINICAL INFORMATION

If you have read, understand, and are happy to continue with your HRT and you do not wish to discuss further, the clinician will look at the answers you provide to the clinical information below. The clinician may contact you to clarify information, but if the clinician is happy with your answers they will issue and send the prescription for you on the date that the receptionist organised the clinician screening review for you to the chemist that you have indicated above.

If you have asked for a further clinician discussion for HRT, or the clinician wants a further discussion, the receptionist will call you for an appointment.

To help the clinician with the prescription, please could you answer a few of the following questions:

Please also click on the links below as suggested by the below questions

Coppafeel! Self Breast Examination (for question 2)
BMI calculation (for question 5)
Alcohol Units (for question 7)
Cervical Smear Screening (for question 8)
Breast Mammogram Screening (for question 9)

DATA PROTECTION AND CONSENT

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. *

I consent to the practice collecting and storing my data from this form.

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Further Information