Final Online Consultation Form

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Welcome to our Online Consultation

To ensure a personalised and unique experience tailored just for you, kindly share a few personal details with us.

PERSONAL DETAILS & VERIFICATION

First Name

Last Name

Phone Number

We ask for your phone number so that our consultant can give you a call and speak to you about your consultation.

Address

Address Line 1

Address Line 2

City/Town

Postcode

Date of Birth

Do you agree and consent to the following?

- I am over 18 years old and live in the UK.
- I will be the sole user of any medication offered to me through this service.
- I confirm all answers are provided by me, and are completely truthful.

Yes

Identity Verification

Please provide a clear and legible photo of yourself holding one of the mentioned identity documents.

Birth Certificate
Full / Provisional Driving License
UK / EU Passport

Identity Verification Document

Choose File

What are your main reasons for wanting to lose weight?

Improving my overall health

Avoiding or managing a specific health condition

Looking and feeling better

Becoming more active

Improving my mood or mental wellbeing

Improving my sleep or energy levels

Other

Select all that apply

Let's Calculate Your BMI

Your Height (cm)

Your Weight (kg)

Your BMI

YOUR BMI IS

YOUR BMI IS which is not suitable for this treatment.

Do you have a goal weight you would like to achieve?

Yes

What is it?

What is your biological sex?

Male

Female

How long have you struggled with your weight?

Last 12 months

Last 5 years

Last 10 years

Most of my life

I’ve never struggled with my weight

What have you tried in the past to lose weight?

Exercise or being more active

Dieting

Calorie counting

Weight loss programs

Weight loss supplements

Meal replacements and shakes

Other

I haven't tried to lose weight

Select all that apply.

Do you suffer from any of the following?

Liver, kidney or heart failure
Pancreatitis
Multiple endocrine neoplasia type 2
Cancer
Type 1 diabetes or diabetic retinopathy
Personal or family history of medullary thyroid cancer
A current eating disorder or a history of an eating disorder? (e.g., anorexia, bulimia, binge eating disorder)
History of gallbladder problem
History of Inflammatory bowel disease or gastroparesis

Do you suffer from any of the following?

Yes

Do you suffer from any of these medical conditions?

Type 2 diabetes
High blood pressure
High cholesterol
Erectile dysfunction
Sleep apnoea
Asthma
Gallbladder disease
Osteoarthritis
Chronic back pain
Depression
PCOS
Fatty liver disease
Chronic malabsorption syndrome

Do you suffer from any of these medical conditions?

Yes

Which ones do you suffer from?

Type 2 diabetes

High blood pressure

High cholesterol

Erectile dysfunction

Sleep apnoea

Asthma

Gallbladder disease

Osteoarthritis

Chronic back pain

Depression

PCOS

Fatty liver disease

Chronic malabsorption syndrome

Are you taking any of the following medications?

Insulin
Sulfonylureas e.g., gliclazide
GLP-1 receptor agonists e.g., Victoza, Saxenda, Wegovy
Orlistat

Are you taking any of the following medications?

Yes

What medication are you taking?

Insulin

Sulfonylureas e.g., gliclazide

GLP-1 receptor agonists e.g., Victoza, Saxenda, Wegovy

Orlistat

Are you taking any other medications?

Yes

Please list your medications and what you take them for?

Do you have any allergies?

Yes

(e.g. Saxenda, Rybelsus, Ozempic, Trulicity or Victoza)

Are you allergic to any of the following?

GLP-1 Medication including Rybelsus, Saxenda, Ozempic, Trulicity or Victoza
Salcaprozate sodium
Povidone K90
Cellulose, microcrystalline
Magnesium stearate

Are you allergic to any of the following?

Yes

If you have any other allergies, please tell us about them.

When considering treatment options, which of the following are important to you?

I want to minimise the risk of common side effects, e.g., nausea

I want to maximise my results

I want an easy and convenient option

I want something that helps me stay consistent

None of the above

Are you pregnant or trying to conceive?

Yes

N/A

Are you breastfeeding?

Yes

N/A

No Recommended Treatment

Based on your medical history there is no treatment suitable for you. If you think you have made an error in your responses, please go back and review your given answers.

Warning: Giving inaccurate information in a clinical consultation, could put your health at risk.

No Recommended Treatment

Based on your allergies there is no treatment suitable for you. If you think you have made an error in your responses, please go back and review your given answers.

Warning: Giving inaccurate information in a clinical consultation, could put your health at risk.

No Recommended Treatment

Based on your answers about pregnancy and breastfeeding there is no treatment suitable for you. If you think you have made an error in your responses, please go back and review your given answers.

Warning: Giving inaccurate information in a clinical consultation, could put your health at risk.

GP DETAILS

Practice Name

Address

Address Line

City

Postal Code

Country

I consent for Prescribe Me to share information regarding any treatment prescribed with my GP.

I consent to a one-off request from Prescribe Me to access my summary care record to verify the information I have provided.

Registered & Regulated By

Superior Health Solutions Ltd is the entity resposible for the prescribing service of PrecribeMe. This service is clinically led and regulated by Care Quality Commission.

The GPhC is the official body that regulates all pharmacists in the UK. They ensure that we prioritise your safety and meet the highest standards.

info@prescribeme.co.uk