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Which treatment are you interested in?

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Your Details

Full Name *

Date of Birth *

I am completing this consultation for myself

I consent to a clinical review by a prescribing pharmacist

Email Address *

Phone Number *

Postcode *

Age Requirement

You must be 18 years or older to proceed with this consultation. Please contact us if you have any questions.

Your Measurements

Height *

Weight *

Waist circumference (cm) *

Your BMI: -

Treatment not suitable based on your BMI

GLP-1 weight loss medication is prescribed under strict clinical rules.

It can only be prescribed if your BMI is 30 or above, or 27 to 29.9 with a weight-related medical condition such as high blood pressure, high cholesterol, or type 2 diabetes.

Your BMI is below 27, so we are unable to offer treatment. This is a safety rule and applies to all patients. If you believe your details are incorrect, please check your height and weight above.

Diet and exercise commitment *

Weight Loss History

Have you previously attempted weight loss? *

Yes No

Methods tried (select all that apply)

Diet Exercise Weight loss medication Surgery

What worked best?

What didn't work or why did you stop?

Target weight (kg) *

Medical Conditions

Do you have any of the following conditions?

Please provide details of any conditions mentioned above

Treatment not suitable based on your BMI

Your BMI is between 27 and 29.9.

At this BMI, GLP-1 medication can only be prescribed if you also have a weight-related medical condition such as high blood pressure, high cholesterol, or type 2 diabetes.

You have not selected a qualifying condition, so we are unable to offer treatment. This is a safety rule and applies to all patients. If you do have a qualifying condition, please select it above.

Medications & Allergies

Do you take any prescription medications? *

Yes No

Please list your medications

Are you currently taking any weight loss medications? *

Yes No

Current Weight Loss Medication

You are currently taking weight loss medication. Please consult with your doctor before starting a new GLP-1 treatment.

Clinical Flag: You are currently taking a GLP-1 medication. A prescribing pharmacist will review your request.

Are you taking Warfarin, Digoxin, or similar medications? *

Yes No

Clinical Flag: You are taking medications that require close monitoring with GLP-1 therapy. A prescribing pharmacist will review your case.

Do you take any medications that cause weight gain? *

Yes No

Which medications?

Do you have any drug allergies? *

Yes No

Please list your allergies and reactions

Allergy Concern

You have reported an allergy to a component of GLP-1 medications. Unfortunately, you cannot safely use these treatments. Please consult with your doctor for alternative options.

Mental Health Screening

Have you experienced depression or low mood in the past year? *

Yes No

Have you experienced anxiety in the past year? *

Yes No

Have you had thoughts of self-harm or suicide in the past year? *

Yes No

Important: Your mental health matters. A prescribing pharmacist will review your case carefully and may refer you to mental health support resources.

Have you experienced rapid heartbeat (tachycardia)? *

Yes No

Do you have retinopathy (eye disease from diabetes)? *

Yes No

Do you experience frequent nausea, vomiting, or diarrhoea? *

Yes No

Pregnancy Status

Are you currently pregnant? *

Yes No

Pregnancy Contraindication

GLP-1 medications are not recommended during pregnancy. Please consult with your doctor before starting treatment.

Are you currently breastfeeding? *

Yes No

Breastfeeding Contraindication

GLP-1 medications are not recommended while breastfeeding. Please consult with your doctor for alternative options.

Are you planning to become pregnant in the next 6 months? *

Yes No

Clinical Flag: You are planning pregnancy within 6 months. Treatment planning will be adjusted accordingly by your prescribing pharmacist.

Are you taking oral contraceptive pills? *

Yes No

Clinical Note: GLP-1 medications may affect the absorption of oral contraceptives. Your prescribing pharmacist will discuss contraception backup options.

Commitment & Follow-Up Care

Can you commit to dietary changes recommended by your prescriber? *

Yes No

Clinical Flag: Your commitment to dietary changes is essential for safe treatment. This will be discussed further with your prescribing pharmacist.

Can you commit to increased physical activity? *

Yes No

Clinical Flag: Physical activity is important for your weight loss journey. This will be discussed with your prescribing pharmacist.

Can you attend follow-up appointments (monthly for first 3 months, then as advised)? *

Yes No

Clinical Flag: Regular follow-up is essential for safe treatment. Please discuss scheduling with your prescribing pharmacist.

Preferred contact method *

Best times to contact you *

Photo Verification

Please upload clear photos for verification. All 4 photos are required.

Photo 1: Government-issued ID *

Click to upload or drag and drop

Photo 2: Weighing Scales *

Click to upload or drag and drop

Photo 3: Full Body (Front) *

Click to upload or drag and drop

Photo 4: Full Body (Side) *

Click to upload or drag and drop

Review & Submit

Treatment: -

Full Name: -

Date of Birth: -

Email: -

Postcode: -

BMI: -

Medical Conditions: -

Medications: -

Photos Uploaded: 0/4

I confirm and declare:

All information provided is accurate and truthful

I understand GLP-1 medications are prescription-only and require clinical review

I will notify my prescriber of any changes to my medical history or medications

I consent to my data being processed for the purposes of clinical review and treatment

I have read and agree to the terms of service and privacy policy

I understand that I may be declined treatment if ineligible following clinical review

Which treatment are you interested in?

Your Details

Age Requirement

Your Measurements

Treatment not suitable based on your BMI

Weight Loss History

Medical Conditions

Treatment not suitable based on your BMI

Medications & Allergies

Current Weight Loss Medication

Allergy Concern

Mental Health Screening

Pregnancy Status

Pregnancy Contraindication

Breastfeeding Contraindication

Commitment & Follow-Up Care

Photo Verification

Review & Submit

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