Request A Call Want to find out more? Please feel free to navigate our website but Dr Whitelaw’s PA Karen is very happy to contact those who wish to talk to someone about their situation and discuss options or maybe you would just like the potential costs explained. A small * symbol denotes a required field.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Title *MissMrsMsMrSirDrProfOtherName *FirstLastEmail Address: *Contact Number: *Date of Birth: *Postcode: *YOUR SYMPTOMS *None Listed (please use additional comment box)Hot FlushesNight SweatsHeart PalpitationsDry SkinWrinkled SkinUrinary IncontinenceVaginal DrynessErection DifficultiesLow LibidoForgetfulness/Brain FogPoor MemoryLow EnergyInsomniaBreast TendernessFluid RetentionPMSBloatingDepressionAnaemiaSleeping DifficultyAnxietyLow Self EsteemMood SwingsAnger/IrritabilityJoint PainIrregular PeriodsHair Thinning/LossLoss of Muscle ToneWeight GainOtherAdditional Comments and/or SymptomsDisabilities, Pre-existing Conditions or Illnesses *No Disabilities, Pre-existing Conditions or IllnessesI have a disability/pre-existing condition/illnessesIf you answered yes, please provide more information in the box below.If you answered yes to the above question (Disabilities, Pre-existing Conditions or Illnesses) please provide a little information about this in the space below:Have you received any hormone treatment? *On BHRT/HRTStopped BHRT/HRT LESS than 6 months agoStopped BHRT/HRT OVER 6 months agoNever been on any BHRT/HRT treatmentProducts/supplements sourced online/in-store (capsules e.g.)When are good times to call you? *Let us know the best times for you. Our usual call hours are Monday to Friday 10am to 4pm.Marketing Preference *PhoneEmailTextNo marketing, thank youWe DO NOT pass details on to anyone else and rarely undertake any direct marketing ourselves.How did you first hear out about Equilibrium Clinic? *GoogleSocial MediaLeaflet/Brochure/MagazineGolf ChicRecommendationOtherConsent and Acknowledgement *By submitting this form I accept that any information provided by Equilibrium will not be considered as clinical advice or recommendation but purely general information about the services offered, how they may help and the possible costs.PhoneSubmit Call Request
