Are you experiencing skin changes you believe are related to menopause (e.g., dryness, thinning, loss of elasticity)?

Have you ever used HRT or topical oestrogen before?

Section 2: Suitability for Estriol 0.3% face cream

Have you ever had breast cancer or are you currently on treatment for it?

Have you ever had another oestrogen sensitive cancer (e.g., womb cancer)?

Have you ever had unexplained vaginal bleeding that has not been investigated?

Have you ever had a blood clot in the leg or lungs, a stroke or a heart attack?

Section 3A: Safety screening

Do you have, or have you ever had, liver disease (including jaundice in pregnancy/while using hormones)?

Are you currently pregnant, breastfeeding or planning pregnancy?

Do you have a history of scleroderma (a connective tissue disease)?

Have you ever had melasma, hyperpigmentation or age spots (H spots) on your skin? Hyperpigmentation is the darkening of patches on your skin

Section 3B: Safety Screening

Are you sensitive to any of these ingredients?

Section 4A: Allergies and medications

Are you currently using any hormonal medicines (e.g., HRT, vaginal oestrogen, contraceptives, testosterone)?

Are you taking any other regular prescription, over the counter or herbal medicines/supplements?

Section 4B: Allergies & Medicines

Please list any medications or supplements you are taking. Put "N/A" if you are not taking any

Please share any other details on skin sensitive or allergies. Put "N/A" if none

Section 4C: Allergies and Medicines

This cream contains a small amount of estriol (a gentle form of oestrogen) alongside skin-supporting ingredients such as vitamin E, hyaluronic acid and niacinamide. It has been developed to help with common skin changes after the menopause, such as dryness, thinning and reduced elasticity.
Because it is a hormone-based medicine, it may not be suitable for everyone. In particular, certain medical conditions &mdash; including breast cancer, some other cancers, blood clots or liver disease &mdash; mean it should not be used. We also need to be sure you are not pregnant or breastfeeding before prescribing.
Please find information here on unlicensed and off-label medication: <a class="c-link" href="https://www.manual.co/pages/unlicensed-and-off-label-medicine" target="_blank" rel="noopener noreferrer" data-stringify-link="https://www.manual.co/pages/unlicensed-and-off-label-medicine" data-sk="tooltip_parent" aria-describedby="sk-tooltip-373772">https://www.manual.co/pages/unlicensed-and-off-label-medicine</a>
By completing this questionnaire, you confirm the information you provide is accurate to the best of your knowledge. The cream is intended for external use on the face only, should be used as directed, and is not to be shared with others.

This cream contains a small amount of estriol (a gentle form of oestrogen) alongside skin-supporting ingredients such as vitamin E, hyaluronic acid and niacinamide. It has been developed to help with common skin changes after the menopause, such as dryness, thinning and reduced elasticity.
Because it is a hormone-based medicine, it may not be suitable for everyone. In particular, certain medical conditions — including breast cancer, some other cancers, blood clots or liver disease — mean it should not be used. We also need to be sure you are not pregnant or breastfeeding before prescribing.
Please find information here on unlicensed and off-label medication: https://www.manual.co/pages/unlicensed-and-off-label-medicine
By completing this questionnaire, you confirm the information you provide is accurate to the best of your knowledge. The cream is intended for external use on the face only, should be used as directed, and is not to be shared with others.

Do you understand this is a hormone based prescription cream for external use on the face only?

Do you understand you may need to stop using the product if you develop unexpected side effects or there is a change in your medical history?

Section 5A: Consent & Understanding

Do you consent to your GP being informed of this prescription?

Please provide your GP details - GP name and practice address. By providing these details you consent to us sharing letters with your GP to update them on any changes to your medications.

Section 5B: Consent & understanding

Estriol 0.3% Face Cream Consultation v3: Pre checkout