Incontinence Prescription

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Do you agree and consent to the following?

You are completing this consultation for yourself and to the best of your knowledge.
You will disclose any medical conditions, serious illnesses or operations you have had.
You will disclose any prescription medications you are currently taking and agree to use only one weight loss treatment at a time.
You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy.
Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life-threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation.
You agree to undergo identification and age verification. This may require submitting valid documents to our approved third-party verification partner for validation.
You consent to EveryDayMeds accessing your Summary Care Record (SCR) for the purpose of ensuring the safe supply of treatment. If the SCR is unavailable or incomplete, you agree to participate in appropriate two-way communication (e.g. phone, secure message, or video consultation) to verify your medical history. If you do not respond or engage, your order will be cancelled.

Your Health

What was your assigned sex at birth?

This online consultation depends on knowing your assigned sex at birth, not your gender identity. We need this to ask clinically relevant questions and recommend suitable treatments.

Male Female

Do you have a history of prostate-related problems?
(This includes any of the following: enlarged prostate, prostate surgery, difficulty urinating, weak stream, or incomplete bladder emptying.)

Yes No

Have you been diagnosed with or experienced any of the following conditions?

Pelvic organ prolapse
Vaginal atrophy (dryness or thinning)
Urethral diverticulum
Pelvic floor dysfunction
Recent gynaecological surgery (e.g., hysterectomy)

Yes No

Have you been diagnosed with urinary incontinence by a doctor following an examination?

Yes No

Have you used medication for urinary incontinence before?

Yes No

Have you been tested for diabetes?

Yes No

Are you pregnant, breastfeeding or planning on conceiving?

Yes No

Do you pass urine more than 8 times during the day?

Yes No

Do you wake up more than once during the night to pass urine?

Yes No

Do you experience any of the following?

Stress incontinence (leakage with sneezing, coughing or exertion)
Urinary urgency or overactive bladder
Mixed incontinence (both exertional and urgency)
Difficulty starting urination or incomplete emptying
Constant urine leakage
Pain when urinating
Frequent UTIs
Leakage after urination
Pain during Sex
Other urinary symptoms

Yes No

Have you been diagnosed with a specific type of incontinence?

Stress incontinence
Urgency / overactive bladder
Mixed incontinence
Overflow incontinence

Yes No

Have you had any recent abdominal or pelvic examinations related to your urinary symptoms?

Yes No

Do you currently experience stomach pain, bloating or swelling?

Yes No

Do you drink large amounts of alcohol or caffeine, or know of any other lifestyle factors contributing to your symptoms?

Yes No

Medical Condition

Have you experienced any of the following in the last few days?

Fever
Pain on urinating
Blood in urine
Sudden-onset lower back pain

Yes No

Do you ever struggle to pass urine?

Yes No

Please provide brief details (e.g. frequency, GP review, severity)

Do you have or have you ever had any of the following?

Glaucoma
Myasthenia gravis
Gastrointestinal obstruction or motility issues
Urinary retention
Significant bladder outflow obstruction
Pyloric stenosis
Paralytic ileus
Angle-closure glaucoma
Toxic megacolon
Ulcerative colitis
Heart conditions (e.g. arrhythmia, heart failure, coronary artery disease)
Hypertension
Kidney or liver disease
GERD or hiatus hernia
Prostatic hyperplasia
Pyrexia (fever)
Autonomic neuropathy
Diabetes
Any other gastrointestinal or cardiovascular condition

Yes No

Please provide more details

Do you currently or have you previously experienced any of the following?

Pelvic organ prolapse
Diverticula (pouches) in your urethra
Vaginal atrophy (thinning or dryness)
Hard lump or mass in pelvis
Blood in urine
Spinal or pelvic injury
Neurological conditions (e.g. Parkinson’s, MS)
Bowel incontinence
Hysterectomy
Dementia
Depression
Any form of cancer
Overactive thyroid

Yes No

Please provide more details

Medication

Are you currently taking any medication for urinary incontinence?

Yes No

Does the medication help with your symptoms?

Yes No

Which medication(s) have you used for incontinence in the past? Please include: - Medication name(s) - Dose(s) - Duration of use - Was it effective? - Any side effects?

Are you currently taking any other medications (prescription, over-the-counter or recreational)?

Yes No

Please provide the name, dosage, and what condition each is used for.

Do you have any known allergies?

Yes No

Please specify what you are allergic to.

Have you had any other medical conditions or surgeries not already mentioned?

Yes No

Please provide brief details.

Agreement

Do you agree to consult your GP within the next 4–6 weeks to review your symptoms and continued need for treatment?

Yes No

Do you confirm the following:

You are using this service for yourself only
You have answered the questions honestly and accurately
You understand the risks and benefits of treatment
You have read and understood the patient leaflet
You will only use the medication as instructed
You will not use this treatment if unsure or contraindicated

Yes No

Do you give us permission to access your NHS Summary Care Record or request medical history from your GP if required?

Yes No

Do you consent to us sharing relevant consultation details with your GP to ensure continuity of care?

Yes No

GP Consultation

We can notify your GP of your treatment for you. To do so, we need their contact information. Sharing this information allows your GP to maintain a comprehensive record of your medical history, which is crucial for your health. Without complete records, there could be potential risks to your well-being.

I consent to EveryDayMeds contacting my GP and share information about my prescription.

Yes No

Practice/GP Name

Practice/GP Address

Identity Verification

Please upload your identification documents.

Would you like to upload documents now?

Upload now Upload later

What you need to upload

To safely prescribe weight-loss medication, our clinicians need to verify your identity and assess your eligibility. Please upload both of the following:

Photo ID

Upload a clear photo of one valid ID document, such as:

Passport
UK driving licence
National ID card

Requirements:

The full document must be visible
Text and photo must be clear and readable
The ID must be valid (not expired)

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Tap to upload ID card

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Full-Body Photo

Take a full-body photo of yourself using your camera.

Photo guidelines:

Full body visible (head to feet)
Wear fitted clothing (no coats or baggy clothes)
Stand straight, facing the camera
No filters or edits

This photo is used only to help our clinicians assess your BMI and suitability for treatment.

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Take photo using camera

Camera required

Upload Previous Prescription

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Upload previous prescription

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If you select this option, your order won’t be approved until all required documents are submitted. After your consultation, we’ll email you instructions on how to upload your documents.