Thyroid Review Form

Once you have completed this form please contact us for the thyroid blood tests.

Once the clinician has your form and blood results they will review the information and contact you if any changes are needed.

Important information for patients:

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.

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

Home Address

Postcode

Best telephone number to contact you

One of the clinicians will call you on the number provided in the next couple of weeks

Review Questions

Are you happy with your current dose?

If no provide details here

Do you have any symptoms?

If yes tell us more about your symptoms

Provide any comments for the clinician here

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Ongar Health Centre • Ongar War Memorial Medical, Fyfield Road, Ongar, Essex, CM5 0AL.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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