HRT Review Form

Last Updated: 04/04/2025

HRT Review Form

This form is only for patients who have already been prescribed HRT for menopause symptoms, are happy with it and would like to continue on the current treatment.

You will need a recent blood pressure reading to complete this form. You can use a home monitoring machine or our surgery pod.

A clinician will review your completed form and will re-prescribe your HRT Medication for up to 12 months if safe to do so.
We will send you a text to let you know. Your HRT will then be available for collection at your norminated pharmacy or reception in a few days.
You should complete this review form every time you would like us to re-prescribe HRT.

If after reviewing your form we need to have a further discussion with you, we will text you to book an appointment.

Your Details

Your Name: *

Date of Birth *

Email Address *

Contact Number *

HRT Review

This form collects your medical information. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form? *

Yes No

Height *

Weight *

Smoking Status *

Have you or any of your immediate family ever had a DVT, gynaelogical cancer, stroke, heart disease or breast cancer? *

Yes No

If yes, please specify

Do you suffer from migraines? *

Yes No

Since your last HRT review, have you experienced any unexpected bleeding? Including: bleeding after sex, bleeding between your periods or (if your periods have stopped) any bleeding more than 12 months after your last period? *

Yes No

Blood Pressure

If you are not able to find a way to measure your blood pessure, you can use the surgery pod in our main reception area. If you give this reading to the reception team, they will update your record.

If you are on HRT which contains Estrogen, a blood pressure reading is a requirement to ensure safe prescribing of this medication.

Recent blood pressure reading: *

Please take time to read the following link below regarding the risk and benefits of HRT

Hormone replacement therapy (HRT) | NHS inform

Please confirm you have read and understood the risks and benefits of HRT *

Yes No

Further Comments:

Text Messaging

We may text you after reviewing your HRT form and will use your mobile number on your record.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Penicuik Medical Practice website

HRT Review Form

We may text you after reviewing your HRT form and will use your mobile number on your record.

Further Information

Connect With Us