HRT consultation

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Name *

First

Last

Date of birth *

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Are you currently taking HRT *

Have you taken HRT before? *

Since you’ve indicated that you are not currently using hormone replacement therapy (HRT), please note that we can only offer topical treatment in your case. If you’ve attempted to order oral HRT, that order will be cancelled, and you will need to place a new order for topical treatments (e.g., patches, gel, ± Utrogestan).

Please confirm that you agree and understand.

If you have any questions or would like more information or guidance before making your choice, please feel free to email or call us directly.

Not using HRT *

We’re sorry, but there are no suitable treatments for you.

The safety and well-being of our patients is our number one priority, and based on your answers, we can’t recommend any of our treatment options. We know this is both frustrating and disappointing, but we want to make sure that we’re putting your health first and that you find the right care.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Since you’ve indicated that you are not currently using hormone replacement therapy (HRT) but have taken it in the past and wish to restart, please note that we can only offer topical treatment in this case.

If you have attempted to order oral HRT, the order will be cancelled, and you will need to place a new order for topical treatments (e.g., patches, gel, ± Utrogestan).

If you have any questions or would like more information or guidance before making a decision, please feel free to email or call us directly.

Please confirm that you agree and understand.

Using HRT before

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you had a hysterectomy? Have you had your womb removed? *

Taking oestrogen without a progesterone, if you still have your uterus, significantly increases the risk of complications from HRT. Please confirm that you are aware of this. If you need further guidance or have any questions, please don’t hesitate to contact us for more information.

Oestrogen and need for progesterone *

I understand and agree
I do not understand, please contact me

Please can you tell us what HRT you are currently taking or have taken before? Select one answer *

Combined HRT patches
Oral oestrogen tablets and progesterone tablets
Topical oestrogen (gel, spray or patches) and progesterone tablets
Other

Please tell us more about your current HRT *

Please can you tell us what HRT you are currently taking or have taken before? Select one answer *

Topical oestrogen (gel, spray, patch)
Oral oestrogen tablets
Other

Please can you provide more details on what oestrogens you have taken previously *

Why did you stop using HRT? *

When did you stop using HRT? Select one answer *

Less than 12 months ago
Between 1 – 3 years
More than 3 years ago

Who originally prescribed this for you? Select one or more answers *

GP
Menopause specialist
Online pharmacy
Other please specify

Please can you tell us who started this medication for you *

How long have you been using HRT? Select one answer *

Less than 3 months
3 to 12 months
1 to 5 years
More than 5 years

Have you spoken to your doctor about the benefits and risks of taking HRT long-term? *

For many women, long-term HRT can provide significant benefits, but it’s essential to have all the information needed to make an informed decision. If you haven’t consulted your doctor yet, please provide your preferred contact details and a convenient time, and one of our experienced menopause prescribers will reach out to you.

Please add your contact details, email or mobile phone number below. *

Have you seen your GP for a review since you started taking HRT? *

If you have not seen a GP since you were first prescribed HRT please can you tell us:

Is the treatment helping with your symptoms?
Are you experiencing any adverse effects from your treatment?
Have you noticed any unexpected bleeding?
Have there been any changes to your physical health since you started HRT?
- If yes please list them here:

Please tell us more about your experiences with HRT *

Have you had any unexpected vaginal bleeding since your last review of your HRT with your GP? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Are you currently using any of these female hormone treatments? Select one or more answers *

Utrogestan or another progesterone
Contraceptive pill
Mirena coil
None of these

Do you already have a supply of this medication? *

Do you agree to the following:

You will make appropriate arrangements to obtain a supply of progesterone from us or your usual provider.
You will continue taking progesterone for as long as you are taking oestrogen.
You understand that taking progesterone is essential for protecting the lining of your womb while on HRT.

Progesterone arrangement *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Taking oestrogen without a progesterone if you still have your uterus (womb) puts you at a much greater risk of developing complications from HRT.

Where do you normally get this medication from? Select one answer *

My GP
Private prescription
Buy online
Other

Please can you tell us more about where you get this treatment from? *

Please can you tell us how you currently take this treatment? Select one answer *

One taken daily
TWO taken for 11 days each month
Other

Please can you tell us the dose and how you take this treatment? *

What symptoms of menopause do you have? Select one or more answers *

Vaginal dryness
Recurrent urine infections
Hot flushes
Night sweats
Mood changes
Sleep problems
Other please specify

Please can you give more details about the symptoms that you are experiencing *

Do you have or have you ever had endometriosis? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

When was your last period? Select one answer *

Less than 12 months ago
Between 12 months and 10 years ago
More than 10 years ago
I have had a hysterectomy

Did you attend your last cervical smear test? Select one answer *

Yes
No
I do not have a cervix

Do you understand that the smear test is an important part of the UK health screening program and can significantly reduce the risk of developing cancer? We encourage you to book your appointment at your earliest convenience. *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Did you attend your last mammogram or breast screening? Select one answer *

Yes
No
I have had a mastectomy

Do you understand that breast screening (mammogram) is an important part of UK health screening and can reduce the risk of developing cancer. We would encourage you to book this at your earliest convenience. *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have or have you been treated for any of the following cancers Select one or more answers *

Breast
Womb
Ovarian
None

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have a family history of breast, endometrial (womb) or ovarian cancer? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any of the following issues with your breasts: Select one or more answers *

Breast tenderness
Swelling
Discharge from the nipple
New lumps or changes to existing lumps
Pain
Discolouration
None of these

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you ever had a heart attack or a stroke? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you currently smoke? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any of the following? Select one or more answers *

Gallstones
Diabetes
Migraines
A blot clot or blood clotting disorder
Porphyria
None of these

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

What is your height in cm? *

What is your weight in kg? *

Have you had your blood pressure monitored in the last 12 months? *

Please can you tell us the last time that you had a review of your physical health with your own doctor or practice nurse? *

Can you please tell us what your last blood pressure reading was? Select one answer *

Low (<90/60mmHg)
Normal (<140/90)
High (>140/90)

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you take any of the following medicines?

Medicines for epilepsy (such as phenobarbital, phenytoin, carbamazepine).
Medicines for tuberculosis (such as rifampicin, rifabutin).
Medicines for HIV infection (such as nevirapine, efavirenz, ritonavir, telaprevir, nelfinavir).
Herbal remedies containing St John’s wort (Hypericum perforatum).

HRT medicine CI *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Optional question

To help support your order if you are currently using HRT please upload a picture showing your current treatment here:

For example:

A current prescription for your HRT
A repeat prescription showing your HRT
A list of medications that you are currently taking
A letter from your consultant or specialist

This is to ensure that this treatment is safe and effective for you

Please upload here

Click or drag a file to this area to upload.

Are you aware that you should stop taking HRT and see a doctor if you experience any of the following:

Yellowing of the skin or whites of your eyes (jaundice)
A large rise in your blood pressure (symptoms can include headache, dizziness & tiredness)
Migraine-like headaches which happen for the first time, with or without disturbed vision
Pain in your chest that spread to your arm or your neck
Signs of a blood clot (painful swelling and redness of the legs, sudden chest pain or difficulty breathing)

HRT Warnings *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

What is your biological sex? *

Male
Female

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Are you currently pregnant or breastfeeding? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any other medical conditions not already mentioned? *

Please provide further details *

Are you taking any other medications that have not already mentioned? *

Please provide details including the names, doses and any adverse effects experienced. *

Do you have any other allergies that you have not previously mentioned? *

Please give us more details on these allergies *

Do you agree and consent to the following?

I am at least 18 years old and live in the UK.
I have the capacity to make decisions about your own healthcare
I shall be the sole user of any medication offered to me through this service.
I confirm all answers are provided by me and are truthful.
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
If prescribed a treatment, I will read the Patient Information Leaflet (PIL) that will be provided.
If prescribed a treatment, I will inform my GP of my treatment and contact them if I have any side effects associated with the treatment.
You agree to our terms and conditions, privacy policy and acceptable use policy
You are aware you will be subject to a soft check to validate your identity using LexisNexis.

Checkboxes *

I agree to the statements and give my consent for any treatment provided.

Are you registered with a GP in the UK? *

(Optional) Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP?

Summary care records

I consent

(Optional) Do you give us consent to write to your GP to share information of this supply and any information we hold about you?

Send information to GP

I consent

Product Category

Important

We review all orders to ensure they’re the best treatment we can offer you. If what you ordered is unsuitable, we will refund part or all of your order.

If we decide what you ordered is unsafe for you, given the other information you provided, we won’t issue any treatment. However, we may call you and suggest alternatives.

HRT consultation

Do you agree and consent to the following?

Conditions

Treatments

Care and policies