Bridge of Allan Health Centre

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Repeat HRT Request Form

Bridge of Allan Health Centre > Your Record > Health Review Forms > Repeat HRT Request Form

Please read the following questions carefully and answer each one as fully as possible. The form will be passed to a GP or Pharmacist so that your prescription can be issued. Sometimes a GP may contact you to discuss your answers if they need further information. Otherwise you can expect your new prescription to be available within 7 days.

Repeat HRT Request
Please use format day/month/year e.g. 12/05/1979
Have you had any irregular vaginal bleeding in between your periods?
Have you had any vaginal bleeding after sex?
Overall, are your menopausal symptoms well controlled on your current HRT?
Would you like to discuss this further with a GP?
Have there been any significant changes in your health since your last review?
(In particular – blood clots, heart disease, strokes and new diagnosis of cancer)
Are you cervical smears up to date AND normal?
Have you noticed any NEW breast lumps or new changes with your breasts?
Are your mammograms up to date AND normal?
Do you currently smoke?

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.

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Bridge of Allan Health Centre

Fountain Road
Bridge of Allan
Stirlingshire
FK9 4EU

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