Hormone Health – Referrals

Do you require a translater?:

YesNo

I prefer to be contacted by *:

Home TelephoneMobile Telephone NumberWork TelephoneEmail Address

Your symptoms - do they relate to one of the following: *

Irregular bleedingMenopausal symptomsOther (please specify below)

How long have you had these symptoms? *

Have you seen a specialist previously?: *

YesNo

Please provide any other useful information you think might be relevant, including results of any tests undertaken.

Do you agree to us contacting you by text: *

YesNo

Your GP details:

Do you consent to us contacting your GP?: *

YesNo