Hormone Replacement Therapy (HRT)

Please complete your confidential clinical assessment. Evaluated by GMC & GPhC registered healthcare professionals.

About You & GP Details

General health baseline, age eligibility and GP consent.

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Are you registered with a GP practice in the UK? *

Do you give us consent to inform your GP about this clinical supply? *

Sharing information with your GP ensures continuity of care.

Do you believe you have the mental capacity to make decisions regarding your medical care? *

Are you 18 years of age or older? *

Menopause & HRT Clinical Review

Clinical evaluation of menopausal symptoms and contraindications.

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Have you already been diagnosed with perimenopause/menopause and previously prescribed or discussed HRT with a GP or specialist within the last 12 months? *

Have you ever been diagnosed with breast cancer, ovarian cancer, or any other hormone-dependent malignancy? *

Are you experiencing unexplained, irregular vaginal bleeding that has not been investigated by a doctor? *

Do you have a personal history of blood clots (DVT, PE) or known thrombophilic disorder? *

Medical History & Concurrent Medications

Safety screening for baseline medical conditions and drug interactions.

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Do you have any severe kidney failure, severe liver impairment, or unstable cardiovascular disease? *

Severe organ disease may affect drug clearance and safety.

Are you allergic to any active medications or excipients commonly used for HRT? *

Including active pharmaceutical ingredients or tablet excipients (e.g. lactose, gelatin).

Are you currently pregnant, planning to become pregnant, or breastfeeding? *

Statutory Patient Declaration

Legal and clinical confirmation before prescriber evaluation.

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Patient Statutory Agreement *

I understand and accept all terms of this HRT online clinical consultation. *

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Treatment Categories

About & Help

Hormone Replacement Therapy (HRT)

About You & GP Details

Menopause & HRT Clinical Review

Medical History & Concurrent Medications

Statutory Patient Declaration

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Assessment

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