Request a prescription

Repeat prescription guidelines for the menopause and PMS clinic at the Trust (Chelsea and West Mid sites)

  • This form is for medication agreed by the clinical specialist in your clinical plan, where your GP is unable to prescribe treatment.
  • A prescription will be supplied if you have had a review within the last six months. You will be contacted if your request is outside of this time-frame.
  • If you have not been reviewed within six months, or if your details do not match our records, you may be called for a review before your prescription can be supplied.
  • Depending upon your postcode, your prescription will either be posted to your registered address or can be collected from the Chelsea and Westminster Hospital pharmacy (CW Medicines).
  • A confirmation text or email will be sent via Patients Know Best.
  • Information for patients who have been recommended testosterone for low libido.



Typically today’s date
This can be found on a previous hospital letter
How often you take the drug
A GnRHa (eg syneral, decapeptly, zoladex, prastap) is not a licenced contraceptive—if you are requesting a drug from this group, you must confirm that you not currently pregnant and using contraception
Complete only if you ticked the third option above
List all known drug allergies—if none, write ‘none’
Please provide a blood pressure reading taken within the last two months—this can be done at home, your GP surgery or a pharmacy
Contributors
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