Tirzepatide – Weight Management (e.g. Mounjaro)

If you are unable to upload images below, please proceed without uploading the images. You will be able to send the images directly to the doctor after your submission. 

Please note that a doctor will conduct a consultation to review your case and assess your eligibility for treatment. You will not be eligible for a prescription and will forfeit the consultation fee if:

1. 1. You submit photos without showing your bare arms, abdomen and thighs.
   2. You submit photos that are edited, determined to be AI-generated, or otherwise not genuine.
   3. You do not have visible excessive body fat (i.e. not eligible).
   4. You submit the clinical form while having any of the “⛔do not proceed” criteria.

• Weight management treatment is for the management of obese patients. The goal of this treatment is to support weight reduction and improve related health conditions when combined with diet, exercise, and lifestyle modifications.
• There is no guarantee of weight loss when using this medication.
• Weight management treatments work by slowing gastric emptying, decreasing appetite, and increasing satiety.
• The treatment is given as a once-weekly injection.
• Treatment is prescribed as per South African medical guidelines. There is no guarantee that the treatment will be 100% effective for you. Please consult with a doctor if you are still symptomatic or not improving.
• I am 18 years or older.
• I am currently living in South Africa.
• I will have an in-person medical consultation at least once a year for comprehensive care and physical examination.
• New Tirzepatide Users: The prescription for new Tirzepatide users is for 2 months, after which a review is needed. Once nearing the end of your prescription please return to this service to receive a repeat prescription for up to 3 months at a time.
• No prescription will be issued if an edited, AI generated or unreal photo is submitted, and no refund will be provided.
• I acknowledge that a doctor will communicate with me via WhatsApp within 24 hours.
• Please note that ID verification is required for all patients
• I confirm that the contact information I have provided is correct and belongs to me. I understand that the platform relies on this information to communicate private healthcare information with me.

Consent:

Tirzepatide information:

Tirzepatide may cause serious side effects, including:

• Inflammation of your pancreas (pancreatitis): Stop using Tirzepatide and seek urgent care if you have severe pain in your stomach area (abdomen) that will not go away, with or without nausea or vomiting. Sometimes you may feel the pain from your abdomen to your back.
• Gallbladder problems: Tirzepatide may cause gallbladder problems, including gallstones. Some gallstones may need surgery. Stop the treatment and seek urgent care if you have symptoms, such as pain in your upper stomach (abdomen), fever, yellowing of the skin or eyes (jaundice), or clay-coloured stools.
• Increased risk of low blood sugar (hypoglycemia), especially those who also take medicines for diabetes such as insulin or sulfonylureas. This can be a serious side effect. Check your blood sugar before you start and while you take Tirzepatide. Signs and symptoms of low blood sugar may include dizziness or light-headedness, blurred vision, anxiety, irritability or mood changes, sweating, slurred speech, hunger, confusion or drowsiness, shakiness, weakness, headache, fast heartbeat, or feeling jittery. Stop the treatment and seek urgent care if you experience these symptoms or if your blood-glucose level is low (<4 mmol/L).
• Dehydration leading to kidney problems: Diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems. It is important for you to drink fluids to help reduce your chance of dehydration. Stop the treatment and seek urgent care if you have nausea, vomiting, or diarrhea that does not go away.
• Severe stomach problems. Stomach problems, sometimes severe, have been reported in people who use Tirzepatide. Using Tirzepatide can lead to gastroparesis (stomach paralysis) in some individuals by excessively delaying food passage into the small intestine. Symptoms can include chronic nausea, vomiting, and abdominal pain. Stop the treatment if you develop these symptoms and seek urgent care.
• Serious allergic reactions. Stop using Tirzepatide and get medical help right away if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.
•  Vision changes: If you have diabetic eye disease (retinopathy), the sudden improvement in blood-sugar control can sometimes make eye changes worse. Please stop the treatment and urgently contact your eye doctor (ophthalmologist) if you experience vision impairment or other changes in vision. If vision loss is sudden or severe, please urgently visit an emergency department.
• Increased heart rate: Tirzepatide can increase your heart rate while you are at rest. Stop the treatment and seek urgent care if you feel your heart racing or pounding in your chest and it lasts for several minutes.
• Depression or thoughts of suicide: You should pay attention to any mental changes, especially sudden changes in your mood, behaviours, thoughts, or feelings. Stop the treatment and consult with our doctors if you have any mental changes that are new, worse, or worry you. If you have thoughts of suicide, urgently call the suicide hotline on 0800 567 567.
• Food or liquid getting into the lungs during surgery or other procedures that use anesthesia or deep sleepiness (deep sedation). Tirzepatide may increase the chance of food getting into your lungs during surgery or other procedures. Tell all your healthcare providers that you are taking Tirzepatide before you are scheduled to have surgery or other procedures.
• The most common side effects of Tirzepatide may include: nausea, diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach, dizziness, feeling bloated, belching, low blood sugar in people with type 2 diabetes, gas, stomach flu, heartburn, and runny nose or sore throat.
• I will stop Tirzepatide if tolerability is poor, and consult with our online doctors for a review. Symptoms of poor tolerability include: persistent nausea/vomiting, prolonged diarrhea, prolonged constipation, abdominal pain, dizziness, weakness, palpitations.
• There is a potential risk of developing medullary thyroid cancer with Tirzepatide use, therefore it is essential to monitor for symptoms of thyroid tumours e.g.:

• mass in the neck 
• painful swallowing
• difficulty breathing (gradual)
• persistent hoarse voice

• Treatment must not be used if you are pregnant, breastfeeding or planning pregnancy.
• Treatment must only be used as prescribed. Do not adjust doses without consulting your healthcare provider.
• Always read the medication leaflet before using the medication.

⛔Please urgently visit your nearest emergency dept or in-person doctor if you are experiencing symptoms such as severe pain, chest pain, difficulty breathing, allergic reactions, dizziness, weakness, or other severe symptoms. Telemedicine services are not suitable for emergency medical conditions.

If you require an invoice for medical aid, please fill out the below

Submitting this clinical form with any “⛔ (do not proceed)” conditions will disqualify you from receiving a prescription.

Please urgently visit your nearest emergency dept or in-person doctor if you are experiencing symptoms such as severe pain, chest pain, difficulty breathing, allergic reactions, dizziness, weakness, or other severe symptoms. Telemedicine services are not suitable for emergency medical conditions.