Wallington Family Practice > Services > Forms > Health Review Forms > Thyroid Review Form

Thyroid Review Form

Step One

Please complete the eReview Below.

Step Two

Arrange to have your “thyroid” bloods taken.

Step Three

We will review your records and contact you with any changes to your medication in the next few weeks.

Things you need to know:

Thyroid treatment is lifelong
It is important that you take your medication everyday
You should have your bloods checked every 1 to 2 years
Most people are well controlled on 100 to 150 mcg of Levothyroxine.

Thyroid Review

First Name *

Last Name *

Email *

Enter Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Are you happy with your current dose? *

Yes

Please tell us any issues you have with your current dose:

Do you have any symptoms? *

Yes

Please tell us more about your symptoms:

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *

I consent to the practice collecting and storing my data from this form.

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