Xenical Consultation – i-Prescribe

This assessment WILL TAKE approximately 3 minutes

"*" indicates required fields

Step 1 of 30

Your Health Consultation

To ensure your medication is safe and suitable for you, we need to collect some essential health information. Please complete the consultation form as truthfully and accurately as possible to allow our prescribers to safely dispense your treatment.

Please provide your full name*

First Last

Address*

Street Address Address Line 2 City Postcode

Email*

Phone*

Date of Birth*

Day

Month

Year

Gender*

Male

Female

Other

Medical Questions

Please ensure all information is accurate and complete to help us personalise your weight loss plan.

Are you curently pregnant, breastfeeding, or planning a pregnancy within the next 3 months?*

GLP-1 medications (such as Mounjaro and Wegovy) should not be used during pregnancy or while breastfeeding. If you are planning a pregnancy, you must stop using GLP-1 medication at least 3 months before.

Yes

Please select how you will measure your height*

Imperial (ft/lb)

Metric (cm/kg)

What is your height? (ft/inches)*

For e.g 4"3

What is your weight? (st/lbs)*

For e.g 6st 3lbs

What is your height? (cm)*

For e.g 152cm

What is your weight? (kg)*

For e.g 56kg

Please tick any of the following conditions you have now or have had in the past:*

Pancreatitis

Liver cirrhosis or a liver transplant

Any form of cancer that is currently being treated by a specialist

Gallstones that have not been removed, Gallbladder infection, blocked bile flow or gallbladder surgery within the last 12 months

Heart failure with shortness of breath at rest

Chronic kidney disease with reduced function (eGFR less than 30ml/min – you can find this information on your kidney function blood test)

Severe gastrointestinal disease, including inflammatory bowel disease (eg ulcerative colitis or Crohn's disease), or gastroparesis (delayed stomach emptying)

Treatment or rehabilitation for excessive alcohol use

Active retinopathy

Chronic malabsorption syndrome

An endocrine (hormone) disorder, such as overactive thyroid disease awaiting radioactive iodine or surgery, acromegaly, Addison’s disease, Cushing’s syndrome, congenital adrenal hyperplasia, or a growth hormone disorder

Any cognitive or memory impairment, such as dementia, that may impact the ability to make decisions

None of the above

Please provide more information

Do you have a personal or family history of medullary thyroid cancer, thyroid cancer, or multiple endocrine neoplasia type 2 (MEN2) syndrome?*

Yes

Have you had bariatric weight-loss surgery or a gastric band procedure (either placement or removal) within the past 12 months?*

Yes

Have you ever had an eating disorder, for example, anorexia or bulimia nervosa?*

Yes

Please provide more information

Have you tried to previously lose weight with exercise and diet alone?*

Yes

Please provide more information, if this has not worked

Are you currently on any injectable weight loss treatment?*

Yes

Where have you had it from?

i-Prescribe

Other

Please choose which treatment you had last*

Upload Screenshot or Image*

Please upload proof (screenshot will work) of any previous treatment you have had from another supplier. Please ensure we can see your name, date of order, drug name and strength. Please note your order will be rejected if you fail to provide us with the relevant proof you already are on going treatment.

Max. file size: 1 GB.

Upload Image*

Please upload a live full body image of yourself from today.

Max. file size: 1 GB.

What is your target weight in kg?

Are you requesting more than one pen today?

Yes

Please provide more information*

Please measure your waist circumference in cm. This is the area just above your belly button, all the way around your waist.*

Do you suffer from any of the following weight related conditions?*

Type 2 Diabetes

Prediabetes

Obstructive Sleep Apnoea

High Cholesterol

Hypertension

Heart Disease

Previous Stroke

None of the above

Are you currently taking any of the following medications?*

Acarbose (an anti-diabetic drug used to treat Type 2 Diabetes Mellitus
Anti-epileptics
Anti-depressants
Amiodarone
Ciclosporin
Digoxin
Iodine Salts
Thyroid medication
HIV medication
Oral anticoagulants such as Warfarin
Antipsychotics including Lithium
Theophyline

Yes

Please state which medication:*

What is your blood pressure?

Do you have any allergies or hypersensitivity to the medication you are requesting?*

Yes

Please specify your allergies.*

Please confirm how many calories you have on a daily basis?*

How much exercise do you do each week?*

Agreement

By providing your consent, you acknowledge that you understand and agree to the treatment plan and associated terms below.

Do you agree that you will keep the pen in a refrigerator (between 2°C to 8°C) once you receive your delivery. If you do not do this, i-Prescribe cannot and will not be held responsible for the medication not functioning as intended. Once you start using the pen, you can keep the pen for 1 month when stored at a temperature below 30°C. This medicine can only be delivered via Royal Mail Special Delivery Guaranteed by 1pm due to it being a fridge item. This delivery service is exempt from any free delivery offers or promotions.

Confirmation*

I confirm the above

Do you agree that you will keep the pen in a refrigerator (between 2°C to 8°C) once you receive your delivery. If you do not do this, i-Prescribe cannot and will not be held responsible for the medication not functioning as intended. Once you start using the pen, you can keep the pen for 1 month when stored at a temperature below 30°C. Do you confirm that if you have not ever had any weight loss medication, you are required to start on the lowest strength. Choosing a higher strength will result in an automatic rejection of your order. A higher strength can only be selected if you have ongoing treatment from us or elsewhere providing there is evidence of treatment.

Confirmation*

I confirm the above

Do you accept that all orders placed for weight loss medication from Friday 2pm onwards, Saturday and Sunday will be shipped out on Monday due to the items being temperature controlled. Please ensure you are able to receive your delivery as i-Prescribe will not be liable for any missed deliveries.

Confirmation*

I confirm the above

Please confirm that you understand the importance of drinking at least 2–3 litres of water each day during this treatment, as not doing so may lead to dehydration and other health issues.

Confirmation*

I confirm the above

In order to continue this treatment, you are required a 5% weight loss over 3 months from starting treatment

Confirmation*

I confirm the above

Please note that if your BMI drops below a safe level, i-Prescribe practitioners will need to adjust or stop your treatment to protect your health.

Confirmation*

I confirm the above

Please confirm that any treatment should be taken with a nutritionally balanced diet with exercise. This is a calorie controlled diet, of which around 30% of the calories come from fat.

Confirmation*

I confirm the above

I confirm that I am 18 years of age or older.
I agree to attend follow-up consultations with i-Prescribe practitioners to ensure this treatment remains suitable for me.
I confirm the medicine requested is for my personal use only.
I will read the patient information leaflet provided with the medicine, paying particular attention to the dosage instructions and possible side effects.
I take responsibility for informing my regular doctor about this online consultation and any changes to my health circumstances.
I confirm that all answers I have provided are truthful and accurate.
I understand that my request will be reviewed by a prescriber, and approval is not guaranteed until they confirm suitability.
I confirm that I have the capacity to make my own healthcare decisions.
I agree to i-Prescribe’s terms and conditions.
I understand that prescribers rely on the information I provide to make safe and appropriate prescribing decisions, and that providing false or misleading information could put my health at risk.

Confirmation*

I confirm the above

It’s essential for your GP to know about all the medications you are taking to ensure you receive the best possible care. Sharing this information helps maintain a complete medical record, including medications prescribed from all sources, hence in order to proceed for Weight Loss treatment we will need your GP details.

Confirmation*

I am happy for i-Prescribe to contact my GP regarding this consultation

Practice Name*

Practice Address*

Street Address Address Line 2 City Postcode

Practice Phone Number*

Consent*

I confirm the details are true and I consent to processing my health data.

Create Account

Do you have an account?*

Yes

Username*

Choose your login username:

Password*

Enter Password Confirm Password

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Untitled

Benefit From Online Assessments

01

Benefit 1

Do it from the comfort of your home.

02

Benefit 2

No awkward face to face appointments

03

Benefit 3

You no longer have to wait for appointments

Need Support?

We want to make sure you get the treatment you need. If you need help completing this assessment, or prefer to complete an assessment over the phone, click below to call us.

Click here to call us

This assessment WILL TAKE approximately 3 minutes

"*" indicates required fields

Step 1 of 19

Your Health Consultation

Please provide your full legal name as it appears on your official government-issued identification.

Your Title*

Prefix

Please provide your full name.*

First Middle Last

Gender

Male

Female

Other

Please provide your residential address exactly as it appears on your official identification or utility records.

Address*

Street Address Address Line 2 City Postcode

Please provide your primary contact details. It is essential that your phone number and email address are current, as our clinical team may need to reach you regarding your consultation or prescription.

Email*

Phone*

Date of Birth*

Day

Month

Year

Are you breastfeeding or currently pregnant?*

Yes

Do you have any medical conditions?*

Yes

Have you been diagnosed with hypomagnesaemia, osteoporosis or gastric cancer?*

Yes

Have you ever suffered from liver or kidney problems?*

Yes

Are you currently taking any medication over the counter, on prescription, herbal or recreational drugs?*

Yes

Are you experiencing any of the following symptoms at least twice a week?*

Select All

Heartburn - a burning feeling in the chest just behind the breastbone that occurs after eating and lasts a few minutes to several hours

Chest pain (not heart-related), especially after bending over, lying down or eating

Burning in the throat, or hot, sour, acidic or salty-tasting fluid at the back of the throat

Feeling of food "sticking" in the middle of the chest or throat

None of the above

Are you experiencing any of the following?*

Difficulty swallowing

Unintentional weight loss

Abdominal swelling

Persistent vomiting

Severe/persistent diarrhoea

Vomiting blood

Blood in your stools or black, tarry stools

Have iron deficiency anaemia

Severe liver problems

None of the above

Are you taking any of the following?*

NSAID anti-inflammatory painkillers (e.g. ibuprofen)

Ketoconazole, itraconazole, posaconazole or voriconazole (used to treat infections caused by a fungus)

Digoxin (used to treat heart problems)swelling

Diazepam (used to treat anxiety, relax muscles or in epilepsy)

Ulipristal (used as emergency contraception or treatment for fibroids)

Phenytoin or Fosphenytoin (used in epilepsy)

Medicines that are used to thin your blood, such as warfarin or other vitamin K blockers.

Rifampicin (used to treat tuberculosis)

Atazanavir, Rilpivirine, Tripranavir, Saquinavir, Nelfinavir, Raltegravir (used to treat HIV infection)

Ledipasvir (used for Hepatitis C treatment)

Ciclosporin or Tacrolimus (in cases of organ transplantation)

St John's wort (Hypericum perforatum) (used to treat mild depression)

Cilostazol (used to treat intermittent claudication)

Clopidogrel (used to prevent blood clots (thrombi))

Vitamin B12, Cyanocobalamin, Hydroxocobalamin

Erlotinib, Dabrafenib, Lapatinib or Pazopanib (for cancer treatment)

Clarithromycin (an antibiotic)

Methotrexate (for cancer or rheumatoid arthritis treatment)

Escitalopram (an antidepressant)

Clozapine (for schizophrenia)

None of the above

Do you have an allergy (hypersensitivity) to medicines containing proton pump inhibitors (e.g. omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)?*

Yes

Have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure, at a time you have been actively taking a proton pump inhibitor?*

Yes

Please provide any additional information that you think we need to know about to safely prescribe your medication (optional)

Declaration and Consent

Please read the declaration below carefully. By submitting this consultation, you confirm that you understand and agree to the following statements.

By submitting this consultation, I confirm that I am aged between 18 and 80 years old and that I am completing this form for myself.

I confirm that the medication requested is for my own personal use only and will not be shared with any other person.

I confirm that all the information I have provided is true, complete, and accurate to the best of my knowledge, and that I have not deliberately withheld any relevant medical information.

I confirm that I have the capacity to make decisions about my own health and treatment.

I will read the patient information leaflet supplied with any medication issued and follow the instructions provided.

I confirm that I am not aware of any allergies, contraindications, or medical conditions that would make this medication unsafe for me, unless I have declared them in this consultation.

I understand that the decision to issue medication lies solely with the prescriber and that submission of this form does not guarantee that a prescription will be issued.

I agree to inform my regular GP of this consultation, any medication issued, and any relevant changes in my symptoms or medical condition.

I agree to seek medical advice from my GP or appropriate healthcare provider if my symptoms do not improve within 14 days, if they worsen at any time, or if I experience any unexpected side effects.

I understand that this service is not suitable for medical emergencies and that I should contact emergency services if I require urgent medical attention.

I confirm that I have read and agree to the i-Prescribe Terms and Conditions and Privacy Policy.

Confirmation*

I confirm the above

Consent*

I confirm the details are true and I consent to processing my health data.

Consultation Completed

Your consultation is now complete. You will be redirected to our secure payment portal to finalize your request. Thank you for providing your information.

Benefit From Online Assessments

01

Benefit 1

Do it from the comfort of your home.

02

Benefit 2

No awkward face to face appointments

03

Benefit 3

You no longer have to wait for appointments

Need Support?

We want to make sure you get the treatment you need. If you need help completing this assessment, or prefer to complete an assessment over the phone, click below to call us.

Click here to call us

This assessment WILL TAKE approximately 3 minutes

Your Health Consultation

Medical Questions

Agreement

Create Account

Benefit From Online Assessments

01

Benefit 1

02

Benefit 2

03

Benefit 3

Need Support?

This assessment WILL TAKE approximately 3 minutes

Your Health Consultation

Declaration and Consent

Consultation Completed

Benefit From Online Assessments

01

Benefit 1

02

Benefit 2

03

Benefit 3

Need Support?

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