Name: Liraglutide (Saxenda | Victoza) New User - Weight Management - Online Prescriptions | Affordable, Quick, Easy - Online Doctor South Africa
Price: 250.00 ZAR
Availability: InStock

Liraglutide (new user) Weight Management Questionnaire

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Details Required
Patient Info
Payment

Date

Time

First Name

Last Name

Contact Number

ID Number

Date Of Birth

Have you used our services before?

Yes

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

What is your current weight in Kilograms (kg)?

What is your current height in Centimeters (cm)?

BMI:

⛔ Please do not proceed. Based on your BMI, you are ineligible to receive a prescription for Liraglutide.

Please click here to WhatsApp our Online Doctors for an instant consultation. They will advise on a treatment route that will suit you personally.

Have you used any weight loss treatments previously?

Yes

What medication or treatments have you previously used?

When did you first notice your increased weight?

Are you pregnant or breastfeeding?

Pregnant

Breastfeeding

Not applicable

⛔ Please Do not proceed, this condition will disqualify you from receiving a prescription.
Please click here to WhatsApp our On Call Doctors for an instant consultation. The doctor will advise on a treatment route that will suit you personally.

Are you using any contraception?

Yes

Not applicable

It is advisable to be on contraception while using Liraglutide as it is contraindicated in pregnancy and breastfeeding.

Liraglutide can cause birth defects and should be stopped at least 2 months before a planned pregnancy. Use the code CONTRA40 to receive a 40% discount on our contraception prescription if needed.

Are you experiencing any of the following symptoms?

Nausea

Vomiting

Diarrhea

Constipation

Abdominal pain

Acid reflux/heartburn

Chest pain

Palpitations

Body swelling

Dizziness

Difficulty breathing

DIfficulty swallowing

Hoarseness of voice

None of the above

Do you have a history of any of the following?

Heart palpitations

Hypertension (High blood pressure)

Heart Disease

Kidney Disease

Liver Disease

Pancreatic Disease

Gallbladder Disease

Stroke

Cancer/Tumours

Myasthenia Gravis

Type 1 Diabetes Mellitus

Hypoglycemia (low blood-sugar level)

Hypotension (low blood pressure)

None of the above

Is your hypertension well controlled?

Yes

Do you have Type 2 Diabetes?

Yes

Are your blood-sugar levels well controlled?

Yes

Are you using Insulin or other injectable diabetic medication?

Yes

Do you or any family members have a history of thyroid problems?

Yes

Do you have any neck growths or masses?

Yes

Have you ever been diagnosed with Multiple Endocrine Neoplasia?

Yes

Do you have a history of an eating disorder e.g. anorexia or bulimia?

Yes

Would you like to be referred to our telemedicine psychologist for regular mental health sessions?

Yes

Do you have any other medical conditions?

Yes

What medical conditions do you have?

Are you currently taking any medication?

Yes

What medication are you taking?

Do you have any allergies including allergies to medication?

Yes

What allergies do you have?

Did you have a blood-pressure reading in the last 3 months?

Yes

⛔(do not proceed - please return to this service once you have checked your blood pressure e.g. self check/local pharmacy/clinic)

What was your latest blood-pressure reading?

Systolic (top number)

⛔ Please Do not proceed, this condition will disqualify you from receiving a prescription. Please click here to WhatsApp our On Call Doctors for an instant consultation. The doctor will advise on a treatment route that will suit you personally. Range must be between 100-139

Diastolic (bottom number)

Is your resting heart rate between 60-100 beats per minute?

Yes

Did you have a blood-glucose reading in the last 3 months?

Yes

What was your latest blood-glucose reading in mmol/L?

⛔(do not proceed - please return to this service once you have checked your blood-glucose level e.g. self check/local pharmacy/clinic)

Have you done blood tests in the last 12 months including kidney function, liver function, thyroid function, cholesterol?

Yes

Were the results normal?

Yes

Upload Results (Optional)

Choose File

In your best interest, we’ll provide a free lab form to complete these blood tests. These tests are important for safe monitoring.

Lab form request sent at no charge (save R250)

Weight loss medication will only be effective when part of a proper diet and exercise plan. If you are not seeing a dietitian, would you like to be referred to our partner telemedicine dietitians?

Yes

I am already seeing a dietitian

Upload 2 recent images of yourself, in underwear, for body composition assessment. - Face the camera in the first image. Show a side profile in the second image. - Avoid showing your face - Use the image above as an example of what is required. **Edited, AI generated or unreal photos will not be accepted. You will not be eligible for a prescription if you do not have excessive body fat.

Choose File

I have read and agree to the Terms and Conditions and Privacy Policy (POPI) of the use of this Website and Service.

Weight loss medication is only effective when used in conjunction with a proper diet and exercise plan. There is no guarantee of weight loss when using this medication.
I understand the questions above and have answered honestly.
I understand that any inaccurate or false information could potentially be dangerous to my health and safety.
The medication that is prescribed is for my personal use only. I understand the side effects and effectiveness of the treatments.
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 our online doctors or visit an in-person doctor if you are still symptomatic or not improving.
I agree to the Terms & Conditions of this platform.
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.
As a user I need to monitor my blood-glucose levels to make sure it does not go low (below 4 mmol/L).
I will seek emergency care if I experience severe side effects such as hypoglycemia (low blood-sugar) or signs of allergic reaction such as difficulty breathing or angioedema (body swelling).
I understand that symptoms of hypoglycemia include: shakiness, sweating, headache, drowsiness, weakness, dizziness, confusion, irritability, hunger, fast heartbeat, and feeling jittery.
I will stop Liraglutide 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 Liraglutide 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
This initial prescription for new Liraglutide users is 4 weeks after which a review is needed. After 4 weeks please return and select the Liraglutide Existing User service.
No prescription will be issued if an edited, AI generated or unreal photo is submitted, and no refund will be provided.

I Agree to the terms and conditions of this Prescription Application and that of the use of this service.

Prescription

Price: R250.00

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Medical Scheme (Medical aid name)

Membership Number

Dependent Code

ICD 10 Code (DO NOT EDIT)

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.

Liraglutide (Saxenda | Victoza) New User – Weight Management

Liraglutide (Saxenda/Victoza) is a daily injectable medication indicated for diabetes and obesity. It is a GLP-1 receptor agonist that reduces hunger by slowing stomach emptying. This leads to a reduced caloric intake and weight loss.

Liraglutide (Saxenda | Victoza) New User – Weight Management

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