Initial testosterone prescription

First name

Surname

Your email address

Hospital number or NHS number

This can be found on a previous hospital letter

Date of birth

Postcode

Nominated pharmacy

Check your clinic letter to see whether your prescription is collected from the hospital or a pharmacy. If the hospital, type 'hospital'. If a pharmacy, please provide the name.

Pharmacy address and postcode

Check your clinic letter to see whether your prescription is collected from the hospital or a pharmacy. If the hospital, type 'hospital'. If a pharmacy, please provide the full address.

Request date

Typically today's date

Date of last consultation

This can be found on a previous hospital letter

Name of product recommended to you

Tostran 2% gel pump pack

Testogel 40.5mg sachet

Other (please state)

Other product

I confirm that I was recommended to start testosterone for low libido at my last menopause appointment

I confirm that I have read and understand the Advice and guidance on testosterone use on how to use testosterone and the potential for adverse side-effects

I confirm this is the first testosterone prescription:

yes

no (repeat prescriptions are only prescribed where explicitly agreed)

I confirm all the details above are correct

Request an initial testosterone prescription