Weight Loss

If yes please provide more details on:

• Medication Name
• Medication Strength
• Date of last dose
• Weight before you started treatment
• If stopped treatment, reasons for stopping
• Any side effects experienced

If Yes, please provide more details

If yes, what methods did you use (e.g., altering diet, increasing exercise, medications)?

If yes, please describe:

If yes, please describe:

If yes, which ones and were they effective?

For cold-storage items such as Wegovy/Mounjaro you agree for us to send out via Royal Mail Tracked 24 delivery with ice packs to maintain the cold chain temperature.

Please note - the stability of the medication cannot be fully guaranteed using this method due to factors out of the control of the pharmacy.

We do our best to ship as fast as possible with the best possible courier, but once the delivery leaves us and is with the courier, things are out of our control. Once your order is approved it will be sent via Royal Mail Special Delivery before 1pm or Royal Mail Tracked 24. This is usually a dependable and reliable service.

You agree to accept the responsibility of rearranging the delivery in the case of a missed or delayed delivery by Royal Mail and agree to deal with any missed or delayed deliveries directly with Royal Mail rather than with the pharmacy. For any deliveries received beyond 48 hours of dispatch please contact us prior to opening to check the medication as it will be outside of the cold chain storage conditions which can effect the product and render it unsafe to use. Where this is due to missed deliveries due to no one accepting delivery at the delivery address you agree that you will be liable for replacement and that the delivered medication will be disposed of via a local pharmacy. Where the delay is due to Royal Mail we will contact them to claim and send replacement accordingly.

You agree and understand that:

• We will inform your GP that you are going to start a new medicine to ensure continuity of your health records. To allow us to do this please provide us with your full GP details including the postcode and the practice contact email address.
• If you are using this service following existing treatment from another prescribing service or are moving from this us to another you agree to allow us to share information for continuity of your health records and treatment. To allow us to do this please provide full contact details of your current treatment prescriber.

(Please note this information is a requirement for our service and if these details are not provided it may lead to your order being delayed or cancelled).

As part of our consultation process, you may require a quick telephone or video call with the pharmacist prescriber to ensure we have all the relevant information and answer any questions you may have.
Can you confirm the best day/time that is convenient for you?

Do you understand and agree to the following?

• You declare that you have provided accurate and truthful answers to all the above questions.
• You will read the patient information leaflet provided with your medication before using your medication if prescribed. If you have any questions you can contact our support team or your GP.
• You will inform both us and your GP of your medication, if you experience any side effects of treatment, if you start any new medication or if your medical conditions change during treatment
• You acknowledge that our prescribers rely on your answers as truthful and honest to base their prescribing decisions accordingly, and that any incorrect or inaccurate information can result in serious and dangerous risks to your health- You understand that this questionnaire is part of a request to the prescriber and the final decision will rest with them.
• You understand that the prescribed treatment and medication is intended exclusively for your personal use only.
• You consent to us sharing consultation information with your GP or future or previous prescriber of this treatment and you give us permission to access your health records via your GP or other healthcare professional to verify any information if needed (Required to ensured continuity of health records). We advise you also share this consultation information with your doctor for him/her to update your medical records.
• You understand that the information provided in this assessment will be reviewed by an independent pharmacist prescriber before your order is processed.
• You agree to consult with your healthcare provider before starting any new medication. 

You agree and understand:

• There may be an increased risk of pancreatitis, gall bladder problems and gallstones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek immediate medical advice.
• Injectable weight loss medications should not be used with any other weight loss medications.
• If you develop any lumps in the neck or a hoarse voice whilst taking this medication, you should stop the medication and immediately speak to your doctor
• Weight loss has been associated with a lowering of mood (depression), and if you are experiencing this, you should stop the medication and speak to your doctor.
• This medication should not be used by those that are trying to conceive or become pregnant. You must discontinue treatment at least 2 months before trying for a child.

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have serious health implications.

You understand that once you have completed this consultation form, we will process your payment. However, please note that this does not guarantee treatment approval. If we determine that you are not suitable for treatment, we will issue a full refund.