Weight Loss Consultation

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_*DO NOT DELETE* Product ID

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_*DO NOT DELETE* Condition ID

Please confirm the following:(Required)

I am 18 years old or above.

I am using this service on my own behalf and of my own free will, and any treatment or advice is for my sole use only.

I will inform my GP of any treatment I have received.

I understand my consultation will not be passed to the Click2Pharmacy online clinical team until I have purchased my preferred treatment.

I agree to Click2Pharmacy's terms & conditions and privacy policy.

I confirm and understand all of the above

Date of Birth(Required)

e.g. DD=14 MM=12 YYYY=1990

Day

Month

Year

What is your sex?(Required)

Which units would you like to use for your weight and height?(Required)

Metric (kg, cm)

Imperial (lbs, ft/in)

Please enter your current weight (kg)(Required)

Please state accurate weight or can cause delays!

Please enter your current height (cm)(Required)

Please enter your weight in stones and pounds*

Stones(Required)

Pounds(Required)

Please enter your height in feet and inches*

feet(Required)

inches(Required)

Your BMI is:

Your BMI indicates you may be eligible for weight-loss treatment. Please continue.

Are you currently taking weight loss medication or have used it in the past?(Required)

Yes

What weight loss medication are you taking?(Required)

Mounjaro

Wegovy

Ozempic

Saxenda

Orlistat

Other

What strength of Mounjaro are you using?(Required)

2.5 mg

5 mg

7.5 mg

10 mg

12.5 mg

15 mg

What strength of Wegovy are you using?(Required)

0.25 mg

0.5 mg

1 mg

1.7 mg

2.4 mg

What strength of Ozempic are you using?(Required)

0.25 mg

0.5 mg

1 mg

1.7 mg

2.4 mg

What strength of Saxenda are you using?(Required)

0.6 mg

1.2 mg

1.8 mg

2.4 mg

3 mg

What medication are you taking and what strength is it?(Required)

When was your last dose taken?(Required)

Within the last 7 days

1–2 weeks ago

3–4 weeks ago

More than 1 month ago

Please tell us approximately when you last used the medication.(Required)

Did you experience any side effects?(Required)

Yes

Please describe the side effects.

Do you currently have any of the following conditions?(Required)

Select all that apply:

Type 1 diabetes

Type 2 diabetes

High blood pressure

High cholesterol

Sleep apnoea

Polycystic ovary syndrome (PCOS)

Heart disease

Anxiety or depression related to weight

Gastroparesis

Gallstones/Gallbladder

Pancreatitis

MEN or thyroid cancers including family history

None of the above

Are you currently taking any prescription medications?(Required)

Yes

What type of medication do you take?(Required)

Select all that apply:

Diabetes medication

Blood pressure medication

Cholesterol medication

Antidepressants

Blood thinners

Other medication

Please let us know what prescription medications you are taking.(Required)

Please list your medications.

Are you currently(Required)

Pregnant

Trying to become pregnant

Breastfeeding

None of the above

Are you currently using contraception?(Required)

Yes

What type of contraception are you using?(Required)

Combined oral contraceptive pill

Progesterone-only pill

Contraceptive implant

Coil (IUD / IUS)

Contraceptive injection

Other

Do you have or have you ever had an eating disorder such as anorexia or bulimia?(Required)

Yes

Please note: If you are experiencing an eating disorder or have concerns about your eating habits, specialised and confidential support is available to help you.

For free advice, guidance, and resources, you can visit the Beat Eating Disorders charity.

Do you give consent for our prescriber to check your NHS summary care records if required?(Required)

Yes

To purchase products from Click2Pharmacy, you must give our pharmacists consent to access your health records.

Please confirm you understand the following medication risks:(Required)

I understand that this medication may increase the risk of pancreatitis, gallbladder issues, and gallstones, and I will seek immediate medical advice if I experience severe abdominal pain.

I understand that injectable weight-loss medications must not be combined with any other weight-loss treatments.

I understand that if I develop neck lumps or experience a persistently hoarse voice, I must stop taking this medication and consult my doctor immediately.

I understand that weight loss and injectable treatments may affect my mood, and I will stop treatment and consult my doctor if I experience symptoms of depression or thoughts of self-harm.

I confirm that I have read and understood all of the above.

Please confirm the following:(Required)

I confirm the information I have provided is accurate and truthful so that Click2Pharmacy prescribers can assess my treatment safely. I understand providing false information may be considered fraud under the Fraud Act 2006 and Misuse of Drugs Act 1971.

I will read and follow the patient information leaflet and understand the potential risks and side effects of the medication.

I consent to Click2Pharmacy contacting me by email, text message, or phone if needed regarding my treatment or order.

I understand I must provide weight verification, such as a video or photo showing my weight on scales.

I will upload proof of valid ID and photo of myself if requested.

I agree to provide evidence of previous prescriptions or medication use if I have taken this treatment before and this is requested.

If required, I understand that I may need to complete a consultation with a Click2Pharmacy clinician before a prescription can be issued.

I confirm all of the above.

Weight Loss Consultation

Weight Loss Service