HRT Questionnaire 

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Personal Details
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In order to provide HRT safely we need to ask you some questions.  We would be grateful if you could complete this form when you submit your repeat prescription request.  If we are having any problems with your HRT medication or would llike to consider alternative options.  Please speak to one of our trained clincians.

If you answered yes to smoking - and would like support in quitting.  Please ask at reception about quitting or visit Live Life better Derbyshire website

If you answered No to the above question please contact reception to arrange your overdue cervical smear and to ask regarding your breast screening review.

Thank you for completing our HRT questionnaire.

If there are any problems with re-issuing your prescription we will contact you.

If not your prescription will be ready for you to collect from your nominated pharamcy within 2 working days.

If you do not have a nominated pharmacy please contact reception and we can set this up on your medical records.

Privacy Consent

This form collects personal and medical informanot tion about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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