Estriol 0.3% + Hyaluronic Acid 0.5% Face Cream Assessment

Your details

Please provide your legal details so our prescribing team can review your request safely.

Email address Sex assigned at birthSelectFemaleMale

This treatment is designed for women or people assigned female at birth who are experiencing perimenopause or menopause-related skin changes and are requesting facial estriol 0.3% with hyaluronic acid 0.5%.

Delivery address

Please tell us where you would like your treatment sent if approved.

Address line 1 Address line 2

Menopause and skin concerns

These questions help us check whether your skin concerns fit the intended use of this treatment.

Which best describes you?SelectPerimenopausePostmenopauseSurgical menopauseEarly menopause or premature ovarian insufficiencyNot sureI do not think I am perimenopausal or menopausal What skin changes are you hoping to improve?

Dryness Loss of elasticity or firmness Fine lines Dullness or reduced radiance Texture changes Increased sensitivity Other

Please describe your main skin concerns Do you currently have any active facial skin condition?

Eczema or dermatitis Rosacea Acne Broken, infected or weeping skin New or unexplained rash None of these

Please provide details

Hormone and medical safety

Estriol is an oestrogen. Hyaluronic acid is included for hydration support. These questions help us identify situations where a prescriber may need more information or where treatment may not be suitable.

Are you currently pregnant, trying to conceive or breastfeeding?SelectNoPregnantTrying to conceiveBreastfeedingNot applicable Do you have a personal history of any of the following?

Breast cancer Womb or endometrial cancer Ovarian cancer Unexplained vaginal bleeding Blood clot, DVT or pulmonary embolism Stroke or TIA Heart attack or angina Liver disease None of these

Please provide details, including dates and any current treatment Have you had a hysterectomy?SelectYes, total hysterectomyYes, partial hysterectomyNoNot sure Are you currently using HRT or any hormonal treatment?SelectYesNo Please list the name, strength and form

Current skincare and medicines

This helps us reduce irritation risk and check for medicines or allergies that may affect suitability.

Are you currently using any prescription skincare on your face?SelectYesNo Please list the products, strengths and how often you use them Are you using retinoids, exfoliating acids or strong active skincare?SelectYesNo Please tell us what you use and how often Do you take any prescription medicines?SelectYesNo Please list them Do you have any medicine, skincare or ingredient allergies?SelectNo known allergiesYes Please provide details Have you ever had irritation, rash or swelling from a hormone cream or facial cream?SelectYesNoNot sure Please provide details

Photos and confirmation

Photos are optional, but they can help the clinical team assess skin type, irritation and overall suitability.

I confirm I am requesting treatment for myself. I understand this request is for facial skin use only and not for vaginal, vulval or internal use. I confirm the information provided is complete and accurate. I understand treatment is subject to clinical review and may be declined or refunded if unsuitable. I am aware that some medicines prescribed to me may be unlicensed medication or used outside the terms of their licence. I agree to read the patient information supplied and seek advice if I develop new or worsening side effects.