About us 2 - Pill Box

Weight Loss Consultation Form

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1About Your Health

2BMI

3Image Uploads

4About You

5About your Weight Loss

6Agreement & Consent

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Name *

First

Last

Phone

Email *

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Please select either Metric or Imperial measurements : *

Metric
Imperial

Height (cm) *

Weight (kg) *

Height (feet) *

Height (inches) *

Weight (stone) *

Weight (lbs) *

Your BMI is: 0

What is your goal weight in the next 4 weeks and how are you planning on achieving this? (e.g. diet, exercise etc) *

Please upload a picture of yourself holding a piece of paper with todays date or your ID (this must show your face!) *

Click or drag a file to this area to upload.

Allowed formats are heic, pdf, jpg, png, gif PLEASE NOTE - ANY MISSED PICTURES WILL DELAY YOUR ORDER

Please upload a FULL body image of yourself which also shows your face. *

Click or drag a file to this area to upload.

PLEASE NOTE - ANY MISSED PICTURES WILL DELAY YOUR ORDER. All pictures are secure, confidential and only seen by the clinical team. If for any religious or any other reason you do not want to show your face, please let us know and we can arrange a video call with a female member of staff.

Please upload a picture of you standing on the scales with the weight reading showing. *

Click or drag a file to this area to upload.

Height should be above 1 ft 10 inches

What is your gender *

Male
Female
Other

What is your date of birth? *

What is your ethnicity? *

Please provide more information *

Do you smoke or drink alcohol?

If so, please tell us how many units per day. You can use the following as a guide:- Pint of beer = 3 units- A can of beer = 2 units- A large glass of red wine = 3 units

Please provide more information *

Do you know if your blood pressure is Low, Normal or High? *

Do you suffer from any allergies? *

Please provide more information. *

Can you walk 3 miles or climb a set of stairs without pain in your chest? *

Please provide more information. *

Do you currently take any medication or recently finished a course of medication? *

Please provide more information. *

Is there a history of medical disorder's within your family e.g. thyroid cancer? *

Please provide more information. *

Do you have a medical condition or take medication that may contribute to your weight gain? *

Examples include growth hormone deficiency, polycystic ovary syndrome, Cushing's syndrome, hypothyroidism, hypothalamic damage (e.g., tumour, trauma, or surgery)

previous more What

Unfortunately the medication is contraindicated in the above conditions.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Do you suffer from pancreatitis or at high risk of thyroid cancer? *

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Have you been diagnosed with any of the following conditions/illnesses: Cholelithiasis (Gallbladder Stones), Cholecystitis, Diabetic Gastroparesis, Inflammatory Bowel Disease (IBD) *

Unfortunately the medication is contraindicated in the above conditions.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Have you ever had any surgery (operations)? *

Please provide more information. *

Have you previously been on a course of any prescription treatments such as Ozempic/Wegovy/Mounjaro/Orlistat/ Xenical/Saxenda? *

Please provide more information *

Are you currently on a course of any prescription treatments such as Wegovy/Mounjaro/Saxenda/Orlistat? *

Please can email us proof on [email protected]. This can be an image with a dispensary label on, or a confirmation email from your previous provider, or anything else similar. Not providing this will delay the order.

Do you have a current or previous history of depression, suicidal thoughts, generalised anxiety disorder or any other psychiatric disorder? *

Please provide more information here. *

Do you think there could be psychological causes for your problem e.g anxiety or depression? *

Please provide more information. *

Do you have a history of having an eating disorder? *

Please provide more information. *

Are you pregnant or breastfeeding? Is there any chance of you being pregnant? *

Unfortunately the medication is contraindicated in the above conditions.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Do you suffer from any of the following *

Please provide more information. *

Have you tried to manage your weight by altering your diet and increasing physical activity? *

Please provide more information. *

Are you aware of any disease in your liver or kidney? *

Please provide more information. *

Have you ever suffered from or had previous history of any heart problems (e.g heart arrhythmias, peripheral arterial disease, stroke or congestive heart problems)? *

Please provide more information *

Is there anything else which you feel we should know about prior to you taking this medication? *

Please provide more information here *

Can you think of any other health / medical details not mentioned above? *

Please provide more information *

Do you agree to the following? *

You declare that I have answered the above truthfully- You will read the patient information leaflet before taking your medication (if prescribed)- You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment- You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health- You understand that this questionnaire is part of a request to the doctor and the final decision will rest with the doctor

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

For cold-storage items such as Wegovy/Mounjaro/Saxenda - are you happy for us to send out via next day delivery with ice packs to maintain the temperature? Please note - the stability of the medication cannot be fully guaranteed using this method so please confirm you are OK with this. *

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

For Wegovy/Mounjaro/Saxenda - will you be using within the next 6 weeks (30 days for Mounjaro)? *

If no - please put straight into the fridge upon delivery.

Do you accept to take on 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? *

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

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

As good practice we must inform your GP that you are going to be starting a new medicine. Please provide us with your full GP details including the post code. (Please note if these details are not provided it may lead to your order being delayed or cancelled).

Can we share this information with your General practitioner and do you give us permission to access your NHS Summary Care Record to verify any information if needed? *

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.

Sorry we need to inform your GP or we are unable to continue with the consultation.

Is there anything else you would like to mention that is not included above? *

Please provide more information *

As part of our consultation process, we may require a quick telephone call with the pharmacist to ensure we have all the relevant information. This also gives us an opportunity to answer any questions you may have. Can you confirm the best day/time that is convenient for you? *

Weight Loss Consultation Form

Unfortunately the medication is contraindicated in the above conditions.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Unfortunately the medication is contraindicated in the above conditions.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Unfortunately the medication is contraindicated in the above conditions.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Sorry. Your answer means that you'll be unable to continue with this questionnaire. Please contact us to discuss.

Sorry we need to inform your GP or we are unable to continue with the consultation.

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