Do you or have you ever had:

• Breast, Ovarian Cancer
• Cancer of the womb
• Hysterectomy (Has your womb be removed?)
• A recent or suspected endometrial hyperplasia, or a history of endometriosis
• A history of liver disease
• Thrombosis such as DVT and Pulmonary embolism, a blood clotting disorder, porphyria
• A heart attack, angina, stroke or other disease caused by a blood clot

Do you currently have or experiencing?:

• Vaginal bleeding, vaginal pain, bloating or swelling in the lower abdomen or pelvis
• Vulval dermatoses
• Vaginal infection, vaginal itching, rash or other skin disorder effecting the genitalia area
• A change in the look/feel of the vulval area such as thickening, shrinking, scarring or a lump

Do you consent to the following?:

• The above questions have been answered truthfully and accurately to the best of my knowledge. I understand that any incorrect information may be detrimental to my health
• The medication is for my personal use only and I am requesting this treatment on my own free will
• I have read the patient information leaflet and will contact a medical professional if I have any questions or experience any unusual side effects while taking the medication
• All information provided will be handle in the strictest confidence in line with the GDPR regulations and I am happy for E Shop Pharmacy to collect and use the information I provide for the purposes of prescribing medicines and to provide treatment for my medical condition
• I am happy to be treated by the prescribers and health care professionals at E Shop Pharmacy and the final decision on whether to prescribe treatment will be with the prescriber and or pharmacist
• I am currently not pregnant or there is no possibility that I may be pregnant
• I understand there is a slight increased risk of patients developing DVT, Stroke, endometrial, ovarian and breast cancer whilst taking HRT medication. I will contact my doctor if I notice any possible signs of a blood clot; jaundice; sudden rise in blood pressure, new vaginal bleeding, spotting or itching; first time onset of migraine-like headaches; onset of symptoms of endometriosis or if a vaginal infection develops or if I feel suddenly unwell which is accompanied by sweating; vomiting or difficulty in breathing; dizziness or a rapid heart rate
• I’ve read and accept the terms & conditions and privacy policy