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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 *

Your BMI: -

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

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

Weight Loss History

Medical Conditions

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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