Request Medication « Lockside Medical Centre

Request by a message

Name*
First Last
Date of Birth*
Telephone*

If there are any problems with issuing your prescription, we may call you to let you know.
Medications required*
If you are requesting an occasional medication (not on your repeat list) please tell us about the condition you are treating.
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Privacy*
- By using this form you agree with the storage and handling of your data by this website. *
Email
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Request your HRT

Name*
Date of birth*
DD slash MM slash YYYY
Telephone*
What is the name of your HRT?*
Is your HRT pill, patch or gel?*
How many years have you been using HRT?*
Please describe your bleeding pattern.*
Have you had a hysterectomy or currently use a mirena coil?*
What is your weight?*
What is your height?*
What is your most recent blood pressure?*
Do you smoke?*
If you do smoke how may cigarettes do you smoke, on average, each day?
Have you been diagnosed with high blood pressure?*
Have you ever had a clot (DVT or pulmonary embolism)?*
Have you ever been diagnosed with breast cancer (or currently having investigations for breast cancer)?*
If you have any problems with your HRT please let us know here.
Patients like to know about the risks and benefits of their treatments. Please visit the NHS website for up to date information on HRT.
https://www.nhs.uk/conditions/hormone-replacement-therapy-hrt/
I have been directed to information about risks and benefits of HRT and am happy to continue taking HRT.*
- I am happy to proceed
Privacy*
- By using this form you agree with the storage and handling of your data by this website. We comply with NHS data protection regulations *
Phone
This field is for validation purposes and should be left unchanged.

Request your Contraceptive

Name*
Date of birth*
DD slash MM slash YYYY
Telephone*
What is the name of your contraceptive?*
What is your weight?*
What is your height?*
Do you smoke?*
If you do smoke how may cigarettes do you smoke, on average, each day?
What is your blood pressure?*

Please take a reading today (either by a home BP device or by using the machine in our waiting room). Readings should include both numbers. If you need help taking a home reading please click on the link below.
http://www.bloodpressureuk.org/your-blood-pressure/how-to-lower-your-blood-pressure/monitoring-your-blood-pressure-at-home/how-to-measure-your-blood-pressure-at-home/
Have you, or a close relative, ever had a blood clot (DVT or pulmonary embolism)?*
Have you ever had a migraine with 'aura'?*
If you are unsure what an 'aura' is, please click on the link below.
https://www.nhs.uk/conditions/migraine/symptoms/
If you have any problems with your contraceptive please let us know here.
Patients like to know about the risks and benefits of their treatments. Please visit the NHS website for up to date information on contraception choices.
https://www.nhs.uk/conditions/contraception/
I have been directed to information about risks and benefits of contraceptives and am happy to continue using my current contraceptive.*
- I am happy to proceed
CAPTCHA
Privacy*
- By using this form you agree with the storage and handling of your data by this website. We comply with NHS data protection regulations *
Name
This field is for validation purposes and should be left unchanged.

LOCKSIDE MEDICAL CENTRE

Request Medication

Request by a message

Request your HRT

Request your Contraceptive