Request Alternative Prescription (Progynova Patches 100mg)

The following details are required prior to issuing your prescription, please complete all of the following to avoid any delays:

(Please note you must be an existing patient to make a request)

Are You On The Monthly Payment Plan?

Yes No

Full Name

Mobile Number

Email Address

Date of Birth

Home Address Line 1

City

Postcode

Are You Under Shared Care With Your GP?

Yes No

GP Practice

List of Medication And Dosage

Last Clinician Seen

Date of Last Appointment

Begin Your Care

The Gender Hormone Clinic

Providing affirmative, patient centred gender affirming hormone therapy led by our expert clinical team and multi disciplinary team of psychiatrists, psychologists and surgeons.

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