Thank you for completing this form. 

We are aiming to avoid the need for you to see a clinician to reissue your HRT prescription. 

Once completed and reviewed, if satisfactory, we will generate your next 12-month supply of HRT.

Scales and a blood pressure machine can be found in the waiting area if you do not have access to them - we are unable to issue a repeat prescription without up-to-date blood pressure and weight measurements.

Personal Details

Medical History