Request for consultation for Low Dose Naltrexone (LDN) or Low Dose Dextrometorphan (LDXM)

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LDN is a treatment used off label/license for autoimmune disease and certain cancers. It is an unlicensed medicine, so is generally only available privately. The consultation costs £40 and is with a Prescriber - the cost of the medicine is separate. Please be aware there will be a charge for repeat prescription(s) privately.

LDXM is also unlicensed and requires a prescription from a Prescriber in the same way.

If your request for LDN is URGENT and you need to be seen this week, please click here.
https://shop.dicksonchemist.co.uk/product/urgent-prescriber-consultation-referred-by-the-ldn-research-trust/

Otherwise continue with this form and you will be referred to Clinic158

At the end of this questionnaire, once you press SUBMIT, you will be requested to upload evidence of the disease you are wishing to be treated for. If you don't have it to hand, don't worry - just skip the step and it can be provided later.

Email *

Which medicines do you require a consultation for? *

LDN low dose NALTREXONE

LDXM low dose DETROMETORPHAN

Both

Dont know

Are you resident in the UK or EU *

YES

Enter your Full Name *

First line of your home address *

Town/City

Postcode of your home address *

Date of Birth (DD/MM/YYYY) *

Contact Telephone Number 1 *

Contact Telephone Number 2

Email address for confirmation: *

List all medicines you are currently taking, including supplements and vitamins. *

Please confirm if you are currently taking LDN/L-DXM medicine?

Brief medical history (What are you diagnosed and treated for? What other illnesses or conditions do you have?) *

Why do you want to try LDN? Which disease? (A list of conditions commonly treated with LDN is available here: https://www.ldnresearchtrust.org/conditions) *

Please give your current GP name and address so that our clinicians can contact them to verify your condition if necessary. *

Choose from below: *

I formally give my consent for you to contact my doctor to discuss my case if necessary

Please do not contact my own doctor, I will provide evidence myself of my condition

I agree to the following statement: I am formally giving Dickson Chemist and their direct clinical GP/NURSE partners permission to use the information I have given for my clinical care. I formally request to be registered as your patient for the purposes of this consultation. *

YES

I understand that Low Dose Naltrexone/Low Dose Dextrometorphan for autoimmune disease or cancer is an unlicensed medicine, used "off label" and as such there is limited clinical trial evidence to support the use of this medicine. (Standards we adhere to can be found here: https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribers-responsibilities) *

YES

I am not currently pregnant or breastfeeding and will notify the Prescriber immediately if my circumstances change.

YES

Clear selection

I understand the Prescriber can withhold my prescription if there are changes in my medical status.

YES

Clear selection

I am going to upload evidence of my clinical diagnosis on the next page (secure server) *

Yes

I can confirm I will read over all information provided regarding the ongoing costs such as consultation and repeat prescription fees. *

YES

Required

A copy of your responses will be emailed to the address you provided.

Submit

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