HRT (Hormone Replacement Therapy) Review Form

HRT (Hormone Replacement Therapy) Review Form

If you have been advised by the surgery to submit a HRT review please use this form.

Please be aware it may take up to 4 weeks for the GP to review this form. You will receive a call or text from the practice once it has been reviewed.

Thank you for you patience.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • HRT (Hormone Replacement Therapy) Form

    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.
    Do you have a hormonal coil in place?
    Do you need contraception? (optional)
    Do you still have periods?
    Have you noticed any change in your bleeding pattern?
    Do you have any problems or side effects with your HRT that you would like to discuss further?
    Do you have any symptoms that are not well controlled on HRT?
    Have you ever had surgery to remove your womb (hysterectomy)?
    Do you have any new breast changes/symptoms?
    Have you or any of your parent(s) or sibling(s) been diagnosed with breast or ovarian cancer?
    Do you suffer with Migraines associated with visual aura, weakness or numbness? (optional)
    Are you currently or have you recently used weight loss medication or injections?
    Do you smoke or vape?
    Do you any allergies? (optional)
    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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Page last reviewed: 14 September 2026