HRT Request Form

HRT Request Form

Only use this form if you are already established on a prescription.

A clinician will review the information and issue a script within 48h of receipt.

We will send it to your nominated pharmacy (if you have already made an arrangement with us.) Otherwise it will be left at reception for you to collect in person.

The prescription will be for a year's supply but it will be dispensed by the pharmacy at intervals. The pharmacy can explain this to you.

If there is a problem then we will contact you on the number you have written above.

 

  • Your Details

    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 also 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.
    Date of Birth
    For example, 15 3 1984

  • Safety questions

    I am happy with my HRT and wish to continue the same prescription
    Smoking Status
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Page last reviewed: 13 October 2025
Page created: 09 October 2025