MEDICATION OR FOLLOW UP REQUEST

DayMonthYear
Request for treatment review +/- repeat prescription
Please complete the following information with any queries you may have so I can review your progress and check that all is going well. If you or I feel that a review appointment would be helpful we can book that too.

There are reports of fake medication being issued or poorly stored or delivered drugs that can affect safety and efficacy. I have identified a reputable online pharmacy that can provide fast and safe delivery of approved medication, following a prescription from me.
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Email*

Confirmation Email
Mobile number*
Are you requesting a repeat prescription?*

Yes - please can I have a repeat prescription of Wegovy?Yes - please can I have a repeat prescription of Mounjaro?Not sure - I need some more advice first
Please leave further info on your queries or concerns at the end and I can get back to you. It may require a formal appointment to discuss - if you would like this anyway, please go ahead and book a follow-up appointment on my website.

If you are experiencing serious problems, it is unlikely they are related to your treatment and you should contact your own doctor, attend A&E or ring 999 as appropriate.

Please note, any appointment with me may not constitute a comprehensive medical assessment as I do not have access to your full medical records. Your own doctor is best placed to provide personal medical advice and you should involve your own doctor if you are having health concerns. I recommend you also inform him or her of any advice I provide, to ensure your medical records are updated, particularly relating to medication.

You can email me at any time if you would like me to remove your data from the system.
What dose Wegovy pen are you requesting a prescription for? Remember, you need to start at the lowest dose but don't need to increase the dose every month if you are getting results at a lower dose. Also, if you are having symptoms you may want to drop down or stay at the same dose for a while until your body gets accustomed to it. But let me know about any symptoms so I can advise.

0.25mg (starter dose)0.5mg1mg1.7mg2.4mg
What dose Mounjaro pen are you requesting a prescription for? Remember, you need to start at the lowest dose but don't need to increase the dose every month if you are getting results at a lower dose. Also, if you are having symptoms you may want to drop down or stay at the same dose for a while until your body gets accustomed to it. But let me know about any symptoms so I can advise.

0.25mg (starter dose)0.5mg1mg1.7mg2.4mg
Date of starting Wegovy

DayMonthYear
Have you noticed any symptoms or problems at all since starting Wegovy?

YesNo
Are you experiencing any of the following? Most of these are common and non-specific and probably unrelated to your treatment, but it's useful to document them.

NauseaVomitingAbdominal painTrouble with injections or injection sitesDiarrhoeaConstipationDizzinessOther
How bad is your nausea on a scale of 1 (minimal - barely notice it) to 5 (terrible - stops me functioning)?

1

2

3

4

5

1 is Minimal, 5 is Terrible
How bad is your vomiting on a scale of 1 (rarely - maybe once a month) to 5 (bad - every day)?

1

2

3

4

5

1 is Rarely, 5 is Daily
How bad is your abdominal pain on a scale of 1 (rarely - maybe once a month) to 5 (bad - several times a day)?

1

2

3

4

5

1 is Rarely, 5 is Daily
Can you tell me more about your pain? Do any of these apply?

Mainly under right ribs / right upper abdomenI have noticed my wee is dark when I get pain or my skin has a slightly yellow tingePain comes and goes in waves - it's difficult to get comfortableIt's a constant painIt's all over - not very specificNone of above
How bad is your diarrhoea on a scale of 1 (rarely - perhaps once a month) to 5 (bad - several times a day)?

1

2

3

4

5

1 is Rarely, 5 is Daily
How bad is your constipation on a scale of 1 (minor problem - perhaps once a month) to 5 (bad - constant problem)?

1

2

3

4

5

1 is Minor, 5 is Constant
How bad is your dizziness on a scale of 1 (minimal - barely notice it) to 5 (terrible - stops me functioning)?

1

2

3

4

5

1 is Minimal, 5 is Terrible
Please provide any further details that you can or note any other symptoms you may be having:
How much do you currently weigh? Would you prefer to give your answer in....*

stones / poundskilograms
Your weight in stones
Please check your answer is correct
and pounds
Your weight in kg*
Please check your answer is correct
Waist measurement in cm*
Hip measurement in cm*
Waist to hip ratio
Have you noticed any improvement in health problems since starting this medication?*

YesNo
That's good to hear. Please explain more*
Have you changed any of your existing medication since starting this medication?*

YesNo
Please provide details:
Current medication / allergies:
Have you changed your eating patterns since starting on this medication?*

YesNo
In what way have you changed what or how you eat?*
Do you feel you are more active since starting this treatment*

YesNo
Please tell me more*
Have you experienced any changes in your sleep on this medication?*

Yes - it's betterYes - it's worse than it used to beNo - I haven't noticed a change
Are you feeling generally more cheerful about life on this treatment?*

YesNo
Do you have any other questions or comments for me or my team?*

YesNo
Please enter them here*
Dr Sally has asked me to pass on the following comments:*
Well done on your weight loss - good to hear that you are tolerating the drug well. Please feel free to book a follow up appointment with me if you need more advice. It's important to ensure you are making sustainable changes that will last once you stop the medication.
Issue prescription?*

No emailYes - send email and comments to be ordered via SomerX once patient has paidYes - send email, no added comments
Date of issue:

DayMonthYear
Date
All done! Now press the SUBMIT button below.

If you don't get taken to a thank-you page, check back that you have filled in all fields and SUBMIT again. Then I'll take a look at anything you have sent me and will send you an email with any recommendations.
Should be Empty:

Request for treatment review +/- repeat prescription

All done! Now press the SUBMIT button below.