Topical HRT

To continue to provide your topical oestrogen safely, we need to review your health status each year for any changes. Therefore, we would be grateful if you could complete this form before you submit your next prescription request.

Self-test equipment is available in the waiting room.

If you would prefer a review with the nurse, please request an appointment to discuss with either Nurse Julie or Debbie C.

Topical HRT


Please provide the readings below.


Additional Questions

Do you smoke? *
Smoking Cessation services are available with SmokeFreeNorfolk on 0800 0854 113.
Do you have a history or are you currently undergoing treatment for breast cancer? *

Important Information

Oestrogen creams may damage latex condoms and diaphragms. Women using these types of contraception should discuss with Nurse Julie or their GP.
If you are between 25-64 years, please ensure your smear is up to date. You will receive an invitation letter when this is due.
Are you breast aware?
More information can be found on the GOV website at or ask at reception for a leaflet.
If you are experiencing any vaginal bleeding after the menopause, this should be investigated promptly. Once you have submitted this form, please request an appointment with Nurse Julie or your GP.