About You

Please answer the following questions truthfully. If you get stuck or need any help, use our CHAT button below or give us a Call on 01639 502860

What is your age?

What is your gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Does Not Apply

What is your Body Mass Index (BMI)?
If you're not sure provide and estimate as we can check this before a prescribing decision is made

Please select either Metric or Imperial measurements :

Metric (Meters and Kilograms)
Imperial (Feet and Pounds)

Height

feet inches

Weight

stone lbs

Check BMI

BMI Calculation :

Are you a smoker or an ex-smoker?
If yes please provide more details

Yes

Do you drink alcohol?
If Yes please provide more details on how many units per week and usually when consumed

Yes

Do you have (or have had) any of the following medical conditions?

Heart condition
High blood pressure
Stroke
Liver disease
Kidney problems
Bowel Disease
Pancreatitis
Gall Bladder disease
a suppressed immune system

If yes please provide more details

Yes

Do you have diabetes?

If yes is this Type I or II?

Yes

Have you had any previous surgeries?

If yes please provide more details

Yes

Do you take any medicines?
Please list all your current prescription medication, medicines you buy including any herbal medicines and recreational drugs if taken.

Do you use levothyroxine (a drug used to treat low thyroid levels)?
If you do, what is your current dose, how long have you taken that dose and when was your latest thyroid blood test?

Yes

Do you use the pill as a method of contraception?
If you do, please tell us which medication you take.

Yes

Do you have any allergies? (including medicines and food)
If yes, please provide details

Yes

About your Journey and Health

Have you ever tried to lose weight solely by food and exercise?
Please provide more information

Yes

What is your ideal weight or size?
You can provide numbers or a vision of what you'd like to achieve

Please provide more information about your living and work conditions
e.g. I live with 2 people and a cat, am a painter and decorator

Are you currently using any weight management products?
If yes please provide more details

Yes

Do you have a history of having an eating disorder?
If yes please provide more details

Yes

Has your family a history of Thyroid Cancer type MTC or MEN 2

Yes

Have you had a serious reaction to any Weight Loss Injection or medicine before?

Yes

Our Prescribing Contract

Do you agree with the following?

You will read the patient information leaflet supplied with your medication.
You will use the medicine only as directed
The treatment is solely for your use.
You have answered all the questions accurately and truthfully.
You understand incorrect information can be hazardous to your health.

Yes

Can we share this information with your General practitioner?
We advise you to share this treatment with your doctor so they can update your medical records. Please provide their address if appropriate.

Yes

Do you agree to tell your doctor or pharmacist about any side effects you may be experiencing with the medicines and any progression of symptoms?

Yes

Is there anything else we need to know that is relevant to this consultation?

Do you agree you will contact us and inform your GP if you start new medication or if your medical conditions change during treatment?

Yes

Click Submit, select the product of your choice and Checkout - you can pay online or choose "Pay at Pharmacy". We can prescribe a different medicine if required. You will need to be registered before checking out.

Yes

Ear Health

Weight Management

Male Health

All Conditions

Weight Loss

About Us

How to check GPhC Registration

Ear Health

Weight Management

Male Health

All Conditions

Weight Loss

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