Weight Loss Treatment

1
I confirm that I am 18 years of age or older, using this service voluntarily and on my own behalf. Any treatment or advice provided is intended solely for my personal use.* This field is required.
Agree
Disagree
2
Consultation Ended

by choosing disagree you no longer can fill out form.
3
Prescription Process

Issued of a Tuesday Only

All Prescriptions will be processed and delivered to you by Molloys Pharmacy. You will be contacted by Molloys Pharmacy about prescription payment and delivery process after approval. The delivery will be within 48hrs.
4
Have you previously being prescribed Weight Loss Medication from Dooctor.ie?
YESNO
5
If you have being prescribed before please click on this form link below.

Weight Loss Repeat Prescription
6
Name* This field is required.
First Name
Last Name
7
Email* This field is required.
example@example.com
Confirm Email
8
Date of Birth* This field is required.
Date
Day
Month
Year
9
Phone Number* This field is required.
Area Code
Phone Number
10
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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Guinea-Bissau
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Ireland
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Jersey
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Kazakhstan
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North Korea
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Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
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Paraguay
Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
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Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
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Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Please specify your gender* This field is required.
MALE
FEMALE
12
Are you pregnant, breastfeeding or trying to get pregnant?* This field is required.
YES
NO
13
This treatment is not suitable if you are pregnant, trying to get pregnant or breastfeeding. We recommend you speak to your GP in person.
14
BMI Calculator* This field is required.Please enter accurate details
15
What is your blood pressure range* This field is required.
Please Select
Please Select
Low (90/60 or below)
Normal (between 91/61 and 139/89)
High (140/90) or above
I am not sure
16
Do you suffer from any heart problems?* This field is required.For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.
YESNO
17
1. Please give details* This field is required.
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Ok
18
Do you have any thyroid problems?** This field is required.For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.
YESNO
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2. Please give details* This field is required.
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Ok
20
Have you, or anyone in your immediate family ever had thyroid cancer?* This field is required.
YESNO
21
3. Please give details* This field is required.
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Ok
22
Do you currently, or have you ever had pancreatitis?** This field is required.
YESNO
23
4. Please give details* This field is required.
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Ok
24
Do you suffer from any kidney problems?** This field is required.
YESNO
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5. Please give details* This field is required.
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Do you suffer from any liver problems?* This field is required.For example: hepatitis, fatty liver, alcohol liver disease etc.
YESNO
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6. Please give details* This field is required.
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Ok
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Do you suffer from any SEVERE gastro-intestinal problems?* This field is required.For example: inflammatory bowel disease or gastroparesis etc
YESNO
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7. Please give details* This field is required.
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Ok
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Do you suffer with diabetes?* This field is required.
YESNO
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8. Please give details* This field is required.
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Ok
32
Do you suffer from any mental health problems?* This field is required.For example: severe anxiety, severe depression, schizophrenia, personality disorders, body dysmorphia, thoughts of suicide etc.
YESNO
33
9. Please give details* This field is required.
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Ok
34
Do you suffer with an eating disorder?* This field is required.For example: anorexia, bulimia, binge eating etc.
YESNO
35
10.Please give details* This field is required.
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Ok
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Do you have any other medical problems?* This field is required.For example: anorexia, bulimia, binge eating etc.
YESNO
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11. Please give details* This field is required.
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Ok
38
Are you taking any other medication not already identified above?* This field is required.For example other prescribed medication, products purchased over-the-counter or herbal supplements
YESNO
39
12. Please give details* This field is required.
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Ok
40
13. Do you have any known allergies?* This field is required.
YESNO
41
13. Please give details* This field is required.
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Ok
Ok
42
Do you smoke?* This field is required.Excessive smoking consumption can increase the risk of serious health issues.
YESNO
43
If YES - How many per day?* This field is required.
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Ok
44
Do you drink alcohol?* This field is required.Excessive alcohol consumption can increase the risk of serious health issues.
YESNO
45
If YES - How many units per week?* This field is required.
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Ok
Ok
46
How many cups of coffee would you drink a day?* This field is required.Please give accurate information
47
How many cups of water would you drink a day?* This field is required.NB. It is very important to stay hydrated when taking this medication in order to reduce potential constipation
48
How many hours of sleep do you average each night?* This field is required.Lack of sleep can affect two important hunger hormones, (ghrelin and leptin) making you feel hungry and increasing your appetite.
49
How much exercise / activity do you do each week?* This field is required.NB. This doesn't have to be set time in the gym, it can be ANY activity that gets your heart pumping. (Current guidelines recommend 150 minutes of moderate aerobic activity or 75 minutes vigorous activity per week)
Please Select
Please Select
Very little
One Hour
Two Hours
More than 3 hours
50
How many calories do you consume per day?* This field is required.
Please Select
Please Select
Less than 1000
1000-1500
1501-2000
2001-2500
more than 2500
51
Please describe your typically daily diet.* This field is required.
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Ok
Ok
52
What contributes to your excess weight? (Please tick ALL that apply)* This field is required.
Large portion sizes
Emotional eating
Compulsive eating
Reward eating
Waking and eating at night
Eating out / Takeaways
Medication
Yo-Yo dieting
Snacking between meals
Lack of exercise
Lack of will power
Lack of motivation
Limited mobility
Other
53
Please tell us what weight loss interventions you have previously tried* This field is required.For example: weight watchers, slimming world, increased exercise, went to see GP, medication etc
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Ok
Ok
54
Are you currently taking any weight loss treatments such as Mysimba, Saxenda, Wegovy, Ozempic or Phentermine?* This field is required.
Please Select
Please Select
None
Mysimba,
Saxenda,
Wegovy,
Ozempic
Phentermine
Mounjaro
55
Specify your current dosage (e.g., "0.25 mg Ozempic")* This field is required.
56
Any side effects?* This field is required.
57
Are you willing to increase dosage (e.g., "happy to go to a higher dose")* This field is required.
58
Do you feel motivated to lose weight at this time?* This field is required.
Not at all motivated
Slightly motivated
Somewhat motivated
Quite motivated
Extremely motivated
59
How motivated are you to change your eating habits at this time?* This field is required.
Not at all motivated
Slightly motivated
Somewhat motivated
Quite motivated
Extremely motivated
60
How motivated are you to increase your physical activity at this time?* This field is required.
Not at all motivated
Slightly motivated
Somewhat motivated
Quite motivated
Extremely motivated
61
How motivated are you to try new strategies/techniques for changing your dietary, physical activity and other health related behaviors at this time?* This field is required.
Not at all motivated
Slightly motivated
Somewhat motivated
Quite motivated
Extremely motivated
62
People who want to achieve long-term weight control need to spend time every day trying to plan for healthy meals, physical activity and behavior change. How confident are you that you can devote time and effort, now and over the next few months?* This field is required.
Not at all confident
Slightly confident
Somewhat confident
Quite confident
Extremely confident
63
How confident are you that you will be able to record everything you eat and drink and your activity each day for 2-4 weeks?* This field is required.
Not at all confident
Slightly confident
Somewhat confident
Quite confident
Extremely confident
64
How satisfied would you be if you achieved a 10% weight loss that significantly improved your health and quality of life?* This field is required.
Not at all satisfied
Slightly satisfied
Somewhat satisfied
Quite satisfied
Extremely satisfied
65
It is our policy to inform your GP when patients start prescription medication for weight management. This is to help your GP avoid any interactions with other medications they may prescribe for you. Please tick 'YES' below to give us your permission to do so.* This field is required.
YESNO
66
GP Name
First Name
Last Name
67
GP Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
68
GP Phone Number
Area Code
Phone Number
69
GP Email Address
example@example.com
70
GDPR Consent Form* This field is required.To assist with your care, we at Dooctor.ie need to collect personal data about you. This information will include details of your health and your treatments. We may also need to record additional information that while may not seem to relate directly to your health it would help in our treatment of you. Examples of this kind of information would include things like your age, gender, marital status, number of children you have, your nationality, your employment status, religion, prison sentences. Our policy is only to collect and record information about you that helps in your treatment. Declaration  I understand my health information will be seen or shared only with medical and administrative staff involved in my care or where Dooctor.ie is required to do so by law.  I understand that for the purposes of my treatment administrative staff may have to access my health data. Reasons for this access would include the re-issuance of prescriptions, the opening of letters and recording of information from hospitals about me, downloading and saving in my file results from laboratories, typing of letters to hospitals and other similar health related issues.  I understand that all Dooctor.ie staff sign a confidentiality agreement that binds them not to disclose my details to any unauthorised persons not involved in my care.  I understand that any health data shared outside of the practice for the purposes of my health treatment will, normally, be limited to information related to a particular treatment and not my entire file.  I understand that my health data will be stored primarily on a secure database operated by a specialist company called Clanwilliam Health and I understand that Clanwilliam Health are only allowed process my health data under Dooctor.ie instructions.  I understand the law provides that in certain instances personal health information can be disclosed, e.g. in the case of some infectious diseases.  I understand that Dooctor.ie will only release information to, for instance solicitors or insurance companies, at my express request.  I understand that I can withdraw consent for processing of my personal health data at any time.
I confirm my consent.
I don't confirm my constent
71
Consultation Ended

by choosing disagree you no longer can fill out form.
72
Kindly TICK to confirm that you agree with each of the following statements if you wish to proceed with treatment, then please sign your name below* This field is required.
I have answered all questions truthfully, and I am aware that It is a criminal offense to give false or misleading information about my health
I am over the age of 18
This prescription request is for my own personal use
I will read the patient information leaflet supplied
I agree to follow the dosing schedule prescribed
I am aware that I must combine treatment with a reduced calorie diet and increased physical activity for best results
I agree to record my daily food intake and physical activity
I am aware that there are no guarantees of weight loss using any of these treatments
I understand that if I have not lost 5% of my initial body weight after 12 weeks of being on the licensed dose, I must discontinue treatment
I wish to commence the Programme if I am found to be a suitable candidate following my consultation, and I consent to treatment
Should I experience any changes in my medical history, I will immediately inform the clinic
73
Weight Loss Package* This field is required.
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Weight Loss Package
If ineligible you will be refunded your fee minus our €50.00 eligibility consultation fee, includes review and consultation.
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