New Patient Referral - Equilibrium Clinic - Hormone Treatment for Menopause and other hormone related conditions

New Patient Referral & Appointment

Please do not use this form if you have not secured an appointment or discussed all elements of the process including all costs with the patient. Please use this form if you wish to simply refer an enquiry – they should enter your name in the ‘referring agent’ field at the bottom.

A small red '*' symbol denotes a required field.

Referring Person's Name *

Patient Title *

Miss
Mrs
Ms
Mr
Sir
Dr
Prof
Other

Patient Name *

First

Last

Patient Email Address: *

Patient Contact Number: *

Patient Date of Birth: *

Patient Postcode: *

Patient Address *

Patient's Symptoms (Please check each symptom/condition below that applies) *

Hot Flushes
Night Sweats
Heart Palpitations
Dry Skin
Wrinkled Skin
Urinary Incontinence
Vaginal Dryness
Erection Difficulties
Low Libido
Forgetfulness/Brain Fog
Poor Memory
Low Energy
Insomnia
Breast Tenderness
Fluid Retention
PMS
Bloating
Depression
Anaemia
Sleeping Difficulty
Anxiety
Low Self Esteem
Mood Swings
Anger/Irritability
Joint Pain
Irregular Periods
Hair Thinning/Loss
Loss of Muscle Tone
Weight Gain

Does patient have any pre-existing conditions, illnesses, allergies or disabilities? *

No pre-existing conditions, illnesses or disabilities
Yes, the patient has pre-existing conditions, illnesses or disabilities:

Complete the section below if you answered Yes.

Details of pre-existing conditions, illnesses or disabilities

Has patient received any hormone treatment? *

On BHRT
On HRT
Stopped BHRT LESS than 6 months ago
Stopped BHRT OVER 6 months ago
Stopped HRT LESS than 6 months ago
Stopped HRT OVER 6 months ago
Never been on any BHRT/HRT treatment
Patient sources products/supplements/vitamins online/in-store:

If products/supplements/vitamins are sourced, please provide details below.

What products/supplements/vitamins are sourced if stated so above?

When is the patient available for an appointment? *

An appointment will be allocated automatically at a time/day specified above but can be rearrange by the patient if not convenient. A confirmation plus details will be emailed to the patient, along with an invoice from our merchant 'Stripe' which should be paid in order to secure the appointment.

Have you outlined the process and costs to the patient? Please tick all that you have discussed. *

Initial Consultation £195
Data and consent form required, with photo ID
Initial Diagnostics (avg. £385 - varies from patient to patient)
Diagnostic Review Consultation £95
Private Medication Costs (up to £3 per hormone per day)
New Patient Treatment Review Consultation £125 (3 months)
Treatment Review Consultation £125 (6 monthly typically)
Further Diagnostics (annually as a minimum requirement but normally only the areas that require monitoring so often not as extensive as the initial ones)

The initial phase of treatment (from first consultation to 3-month review) is the most costly phase, averaging around £800 in total. The doctor will determine each review period and ongoing diagnostic requirements based on a patient's individual treatment needs.

What is the patient wanting? *

Initial consultation only
Initial consultation and diagnostics
Initial consultation but unsure whether they will want diagnostics

Patient's Marketing Preference *

Phone
Email
Text
No marketing, thank you

We DO NOT pass details on to anyone else.

Website

Read our February 2020 article in the Daily Mail

Read our February 2020 article in the Birmingham Post