Hormone Questionnaire (Women)

The following questionnaire is for women wishing to learn more.  Once your questionnaire has been received you will hear from Dr Whitelaw’s assistant if this has been requested.  All information is treated as confidential and is not passed to any third party for marketing purposes.  ‘*’ denotes a required field.

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Title
Name
Please check each symptom/condition below that applies to you:
have you taken HRT?
Do you have an appointment booked?
Marketing Preference (Occasional - Equilibrium Clinic Only)
We DO NOT pass our customer list on to anyone else, nor do we make regular marketing contact.