Assessment Clone – i-Prescribe

Name(Required)

Prefix First Last

Email(Required)

Phone(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Other

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

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

Medical Questions

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

Please select how you will measure your height(Required)

Imperial (ft/lb)

Metric (cm/kg)

What is your height? (ft/inches)(Required)

For e.g 4"3

What is your weight? (st/lbs)(Required)

For e.g 6st 3lbs

What is your height? (cm)(Required)

For e.g 152cm

What is your weight? (kg)(Required)

For e.g 56kg

Please tick any of the following conditions you have now or have had in the past:(Required)

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?(Required)

Yes

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

Yes

Have you ever had an eating disorder, for example, anorexia or bulimia nervosa?(Required)

Yes

Please provide more information

Have you tried to previously lose weight with exercise and diet alone?(Required)

Yes

Please provide more information, if this has not worked

Are you currently on any injectable weight loss treatment?(Required)

Yes

Where have you had it from?

i-Prescribe

Other

Upload Screenshot or Image(Required)

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.

Please choose which treatment you had last(Required)

What is your target weight in kg?

Are you requesting more than one pen today?

Yes

Please provide more information(Required)

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

Do you suffer from any of the following weight related conditions?(Required)

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?(Required)

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:(Required)

What is your blood pressure?

Do you have any allergies or hypersensitivity to the medication you are requesting?(Required)

Yes

Please specify your allergies.(Required)

Please confirm how many calories you have on a daily basis?(Required)

How much exercise do you do each week?(Required)

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. 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(Required)

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(Required)

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(Required)

I confirm the above

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

Confirmation(Required)

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(Required)

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(Required)

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(Required)

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(Required)

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

Practice Name(Required)

GP Practice Address(Required)

Street Address Address Line 2 City Postcode

Practice Phone Number(Required)

Create Account

Do you have an account?(Required)

Yes

Username(Required)

Choose your login username:

Password(Required)

Enter Password Confirm Password

Strength indicator

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country