HRT REPEAT REQUEST FORM

For repeat issues, please complete this form and a member of the team will contact you if required. If you would like to discuss new treatment, then please book in for an appointment with a doctor.

YOUR DETAILS





HRT QUESTIONNAIRE











HEALTH QUESTIONNAIRE

Completing this section will help us get your prescription to you quicker.






DISCLOSURE - 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 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. By completing this form, you consent to the practice collecting and storing the data on this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

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Page last reviewed: 27 May 2022
Page created: 14 October 2026