This form is intended for patients who are considering starting HRT as well as patients already on HRT Information provided is CONFIDENTIAL and will provide the reviewing practitioner key information to ensure the safe prescribing of HRT Please ensure you complete each question and read the text of the page (inclduing the information on the links below) as well as the last section "What Happens Next?"
Family history of breast cancer: Should I take HRT? - The Menopause Charity
One of our practitioners will get in contact with you via telephone to confirm the above information and to discuss the best options available for you
It is perfectly safe to stop HRT suddenly however, some patients would prefer to slowly wean off HRT If you would like to discuss this with a practitioner please tick the above box
One of our practitioners will review the information you have provided and will contact you via telephone to further discuss.
A practice pharmacist or GP will review the information you have provided and they may contact you. Alternatively they may issue a prescription to your preferred pharmacy and they will send you a text message to your mobile phone advising you about this.
This form is not a replacement for an appointment, the information submitted within the form is to be used along side the appropriate appointment. If you need to book an appointment and you have run out of medication, please contact the surgery via 02920 498181 and speak with a member of staff.
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to
The Penylan Surgery | Meddygfa Penylan
72 - 74 Pen-Y-Lan Road | 72 - 74 Heol Pen-Y-Lan, Cardiff | Caerdydd, CF23 5SY.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.