Prescription Renewal Request Eligibility Requirements Before completing this form, please confirm that: You are an existing patient of the Menopause and Wellbeing Clinic. You have been seen by Dr. Casey Bye within the last 12 months. Your breast screening (mammogram, ultrasound or MRI) is up to date. If you do not meet these requirements, or if you have new symptoms or concerns, we will request that you book a face-to-face consultation instead. Full Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### Breast Screening Details Date of Most Recent Breast Imaging: MM DD YYYY Medication Renewal Request - Please tick the medications you are requesting and provide your current dose. Estrogel 1 pump 2 pump 3 pump 4 pump Prometrium Cyclical (2 capsules days 15-26) Continuous (1capsule every night) AndroFeme 0.25ml 0.5ml 0.75ml (your testosterone blood level must been checked within the last 12 months) Vaginal Oestrogen Ovestin cream Ovestin pessaries Intrarosa pessaries Additional Comments * Financial Consent I understand that a fee of $50 is payable before the prescription is issued. Thank you!
