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This form is only to be made AFTER you have made a Menopause Booking, you will need to fill out this form to include your medical details.

Menopause Booking Information Form

Current Medical History (please add any additional medical history in the box below)
Breast Cancer
Blood Clot Disorders (including DVT/PE)
Heart Disease
Medication History
Any prescribed or over the counter medication
Are you on HRT?
Do any of your family have history of breast cancer?
I hereby give consent to Sante des Femmes Clinic to share details of my medical treatment with my GP
I consent to receive text messages, phone calls or emails from Sante des Femmes regarding my health
I would like to request a chaperone to my medical appointment

Thanks for submitting! We will be in touch about a date and time for your Menopause Service Appointment.

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