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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.

Make a Booking

Menopause Booking Information Form

First Name

Last Name

Phone

Birthday

Address and Eircode

GP Name

GP Address

Preferred Pharmacy and Address

Height (cm)

Weight (kg)

Blood Pressure Reading

Date of last menstrual Period (dd/mm/yyyy)

Current Medical History (please add any additional medical history in the box below)

Breast Cancer *

Yes

Hypertension *

Yes

Diabetes *

Yes

Blood Clot Disorders (including DVT/PE) *

Yes

Heart Disease *

Yes

Stroke *

Yes

If yes, please provide more information below

Medication History

Any prescribed or over the counter medication *

Yes

If yes, please list below.

Are you on HRT? *

Yes

If yes, please list below

Do any of your family have history of breast cancer? *

Yes

I hereby give consent to Sante des Femmes Clinic to share details of my medical treatment with my GP *

Yes

I consent to receive text messages, phone calls or emails from Sante des Femmes regarding my health *

Yes

I would like to request a chaperone to my medical appointment *

Yes

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

Santé des Femmes

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Services

Visit us:

Menopause Clinic Blackrock Surgery

Main Street Blackrock,

Co. Louth,

A91 DX6K

Tel: 083 0721780

Mail Us:

info@complexmenopauseclinic.com

Website by Opus Web Design

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Santé des Femmes

Women's Health Clinic

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)

Medication History

Santé des Femmes

Quick Links

Services