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Menopause Registration
Please submit this form to request our menopause and HRT service.
7
Questions
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1
Name
*
This field is required.
First Name
Last Name
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2
Email
*
This field is required.
Please enter a private email address
example@example.com
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3
Mobile Number
*
This field is required.
Please enter a private mobile number
Please enter a valid mobile number.
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4
Date of Birth
*
This field is required.
/
You must be over 18
Day
Month
Year
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5
How often do you get your period?
*
This field is required.
Please Select
Regularly
Irregularly
None in the last 12 months
Please Select
Please Select
Regularly
Irregularly
None in the last 12 months
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6
Are you currently taking any HRT or anti-depressants?
*
This field is required.
Please Select
Yes
No
Please Select
Please Select
Yes
No
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7
Which service are you seeking?
*
This field is required.
Please Select
Standardised Body-identical HRT
Personalised Bio-identical HRT
Testosterone HRT
Please Select
Please Select
Standardised Body-identical HRT
Personalised Bio-identical HRT
Testosterone HRT
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