MediClick Pharmacy

Weight Loss Consultation

Product Id

Let’s Get Started

Let’s Get Started

Choose the type of weight loss treatment you’re interested in:

Weight loss treatmentOral Tablets I would prefer tablets that help reduce fat absorption to support weight loss.Injectable Pens I would prefer a weekly self-injection that helps control appetite and support weight loss.

Weight

Weight Assessment

Weight Assessment

Your Height *

Height

Weight *

Your Weight

Result

BMI Result

Do you have any of the below conditions? If Yes, please select which ones. *YesNo

Select ConditionsPrediabetesDiabetesHeart diseaseHigh blood pressureHigh cholesterolObstructive sleep apnoea

To meet regulatory requirements, patients are required to upload a recent full-body photograph to help verify weight.

The photo must meet the following criteria:

Face and feet clearly visible
Taken in well-fitted clothing (not loose or baggy)
Taken within the last 4 weeks

This image is used solely for clinical assessment and will be handled with strict confidentiality.

Upload a recent full-body photograph *

Drag and Drop (or) Choose Files

Oral Tablet

Medical History

Medical History

Have you ever been diagnosed with an eating disorder (e.g. Anorexia or Bulimia)? *YesNo

Are you pregnant, breastfeeding or planning to be? *YesNo

Are you allergic to Orlistat? *YesNo

Have you ever suffered from an eating disorder? *YesNo

Acromegaly or any growth hormone problem *YesNo

Do you have any of the following diseases/conditions? *YesNo

Check below optionsChronic malabsorption syndromeCushings SyndromeLiver, kidney, or thyroid problemsGastric Surgery (bariatric surgery)Heart FailureHypoglycaemiaPancreatitisSevere gastrointestinal disease (e.g. inflammatory bowel disease, ulcerative colitis, Crohn's disease)Type 1 DiabetesGallbladder removal or bile flow issuesAny serious condition requiring hospitalisation

Any other medical conditions not listed above? *YesNo

Please specify

Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome? *YesNo

Do you have a diagnosed lactose intolerance or difficulty digesting dairy products?YesNo

Please provide details

Have you ever been diagnosed with a mental health condition, or are you currently receiving support for your mental wellbeing?YesNo

Please provide details

Injectable Pens

Medical History

Medical History

If diabetic, are you using any medication other than metformin? *YesNo

Please specify

Have you had an allergic reaction to Wegovy, Mounjaro, Saxenda, Semaglutide or Liraglutide? *YesNo

Have you ever had an eating disorder? *YesNo

Are you pregnant, breastfeeding or trying to conceive? *YesNo

Have you been diagnosed with or had surgery for any of the following? *YesNo

Select optionsHormone conditions (e.g. Acromegaly, Cushing’s)Gallbladder, liver, kidney or pancreatic diseaseGastrointestinal disease (e.g. Crohn’s, IBD)Type 1 DiabetesBariatric (weight loss) surgeryHeart failure or severe hypoglycaemia

Any other medical conditions not listed above, please specify?

Do you or your family have a history of thyroid cancer or MEN2 syndrome? *YesNo

What weight loss methods have you tried? *ExerciseDietingWeight Loss ProgrammesMeal ReplacementsI haven’t tried yet, OtherOther

Please specify *

What challenges have you faced? *CravingsSnackingHungerLack of motivation for exerciseOther

Please specify

What is your goal weight? *

What was your sex assigned at birth?MaleFemale

If you have previously used an injectable weight loss medication, please upload proof of this from your previous supplier. The document or image must clearly show:

(Acceptable forms of proof include a photo of the prescription label or an email confirmation showing these details.)

Your Full Name

The medication name and strength

Upload Photo

Drag and Drop (or) Choose Files

Oral Tablet

Medication Check

Medication Check

Are you currently using an oral contraceptive? *YesNo

Are you taking medication for high cholesterol, diabetes, or blood pressure? *YesNo

Are you taking steroids or medication to treat your thyroid? *YesNo

Are you taking any of the below medications? *YesNo

Select below optionsOther Anti-Obesity DrugsHIV MedicationFat Soluble VitaminsOral anticoagulant drugs used to thin the blood such as WarfarinCiclosporin, used after organ transplants, for severe rheumatoid arthritis and some severe skin conditionsa thyroid medicine (levothyroxine)Iodine saltsAmiodarone, used for heart rhythm problems.Acarbose (an anti-diabetic drug used to treat type 2 diabetes mellitus)Anti-convulsant/anti-epileptic drugsAntidepressantsAntipsychotics including lithiumBenzodiazepines including diazepam

Are you currently taking any medication (including over-the-counter, prescription or recreational)? *YesNo

Please Specify

Injectable Pens

Medication Check

Medication Check

Are you currently taking any medication (including over-the-counter, prescription or recreational)? *YesNo

Please provide details

If yes, are any of the following included? *Amiodarone, Carbamazepine, CiclosporinClozapine, Digoxin, FenfluramineLithium, Methotrexate, Phenobarbital, PhenytoinSomatrogon, Tacrolimus, Theophylline, Warfarin

Are you taking steroids or thyroid medication? *YesNo

Have you used injectable weight loss medication in the past 4 weeks? *YesNo

Do you have a diagnosed lactose intolerance or difficulty digesting dairy products?YesNo

Please provide details

Have you ever been diagnosed with a mental health condition, or are you currently receiving support for your mental wellbeing?YesNo

Please provide details

Any other medical conditions not listed above?YesNo

Please specify

GP Notification

GP Notification

GP Notification Permission

Consent *

Do you consent for us to share details of your treatment with your GP?

Please enter your GP’s details (GP Name, Telephone Number, Address, Post Code)

GP Practice Name *

GP Email Address

GP Phone Number

Street name *

City, town, village *

Post code *

About You

About You

About You

Patient Full Name *

Date of Birth *

Email Address *

Contact Number *

Are you between the ages of 18 and 74?YesNo

What was your sex assigned at birth?MaleFemale

House name

House number *

Address *

City, town, village *

Post Code *

Oral Tablet

Agreement

Agreement

Please confirm the following *YesNo

HTML

I will read the patient information leaflet with my medication
Do you understand that you will be asked to provide evidence of a prescription with an alternative provider if the following applies to you:
- This is your first order of with MediClick Pharmacy and you do not order the starter dose
- Your last order with MediClick Pharmacy was more than 8 weeks ago and you wish to order a higher strength
I will inform MediClick and my GP if I experience side effects or if my medical conditions change
I understand the possible side effects of using injectable weight loss medications.
This treatment is for my personal use only
I have answered all questions truthfully

Please confirm the following *YesNo

HTML

I understand GLP-1 injections may reduce oral contraceptive effectiveness
I understand this medication should not be used if trying to conceive or within 2 months of doing so
I understand there is a small risk of pancreatitis or gallbladder problems and will seek advice if I experience abdominal pain
I understand not to combine this treatment with other weight loss medication
I understand I must contact my GP if I notice lumps in the neck or a hoarse voice
I understand this treatment may affect mood and I will stop use and contact my GP if needed

I agree to the Terms & Conditions and confirm I am over 18

Injectable Pens

Agreement

Agreement

Please confirm the following *YesNo

HTML

I will read the patient information leaflet with my medication
I will inform MediClick and my GP if I experience side effects or if my medical conditions change
This treatment is for my personal use only
I have answered all questions truthfully

Please confirm the following *YesNo

HTML

I understand GLP-1 injections may reduce oral contraceptive effectiveness
I understand this medication should not be used if trying to conceive or within 2 months of doing so
I understand there is a small risk of pancreatitis or gallbladder problems and will seek advice if I experience abdominal pain
I understand not to combine this treatment with other weight loss medication
I understand I must contact my GP if I notice lumps in the neck or a hoarse voice
I understand this treatment may affect mood and I will stop use and contact my GP if needed
I understand the possible side effects of using injectable weight loss medications

I agree to the Terms & Conditions and confirm I am over 18

Consent *

I agree to the assisted prescribing service, if eligible. Learn More

closeWhat is assisted prescribing? We use assisted prescribing to safely speed up low-risk prescriptions, handled by our secure system built and approved by UK clinicians. All complex cases are reviewed by a qualified prescriber.

Copyright © 2025 © Mediclick Pharmacy, All Rights Reserved.

MediClick Pharmacy trading under Pill Post Limited.
Company number: 14807394
Pharmacy GPhC registration number: 9012180
Superintendent Pharmacist: Adeel Abid (GPhC 2218846)

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