Weight Management Repeat Prescription Weight Management Repeat PrescriptionEnsure Safer Prescribing GUIDANCEThe following form is for existing Dokta weight management patients to order new medication. Please complete as fully as possible. Your prescription will be issued within 24 hours of receipt.Patient DetailsFirst NameLast NameDate of BirthEmailWeight MeasurementEnter your weight in Stones and Pounds, or Kilograms.StonesPoundsKilogramsWeight (Kg)Beneficial ResponseClick any good effects you've noticed from taking the medication.Appetite reduced? Yes NoSmaller portion sizes? Yes NoReduced cravings? Yes NoImproved mood? Yes NoOther beneficial effect(s)Side-effect Check ListAny side-effects noticed in the past 1 monthNausea- Select -NoneMildModerateSevereVomiting- Select -NoneMildModerateSevereConstipation- Select -NoneMildModerateSevereDiarrhoea- Select -NoneMildModerateSevereAbdominal pain- Select -NoneMildModerateSevereAbdominal bloating- Select -NoneMildModerateSevereIndigestion or heartburn- Select -NoneMildModerateSevereFatigue- Select -NoneMildModerateSevereDizziness- Select -NoneMildModerateSevereOther side-effect(s)Severe side-effectsYou will need to seek healthcare advice urgently if you answer Yes to any of the following questions:Severe or persistent abdominal pain Yes NoPain spreading to your back Yes NoRepeated vomiting or dehydration Yes NoYellow skin or eyes Yes NoNew Medical HistoryHave you been diagnosed with any new medical problems or started on any regular medication since your last review?Any new medical problems? Yes NoIf yes, which one(s)Started any new medication? Yes NoIf yes, which one(s)Pregnancy & ContraceptionRequired section for womenAre you pregnant? Yes NoAre you currently trying to conceive? Yes NoAre you breastfeeding? Yes NoAre you using contraception? Yes NoConsentIn order to continue with treatmentI wish to continue treatment YesI understand the risks YesI agree to ongoing monitoring YesCurrent Medication DetailsWhich medicine and dose are you taking NOWCurrent Dose of Mounjaro (tirzepatide) 2.5mg 5mg 7.5 10mg 12.5mg 15mgCurrent Dose of Wegovy (semaglutide) 0.25mg 0.5mg 1mg 1.7mg 2.4mgCurrent Dose of Ozempic (semaglutide) 0.25mg 0.5mg 1mgMedication RequestedWhich medicine and dose would you like to REQUEST. Please note that a clinician may get in touch to discuss any changes to your request.Requested Dose of Mounjaro (tirzepatide) 2.5mg 5mg 7.5 10mg 12.5mg 15mgRequested Dose of Wegovy (semaglutide) 0.25mg 0.5mg 1mg 1.7mg 2.4mgRequested Dose of Ozempic (semaglutide) 0.25mg 0.5mg 1mgQuantityHow many pens do you want.No. Pens Requested 1 2Different Delivery AddressOnly complete if you would like delivery to a different address to your home addressAddressAddress Line 1Address Line 2Town/CityCountyPost CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweRepeat Prescription FeePayment ItemPrice: £25.00Pay with Card (Stripe)Submit
