Weight Care

Are you between 18 and 75 years of age? *

Please provide your height: *

Please provide your current weight: *

BMI *

What is your ethnicity? *

Women only: Are you currently pregnant, breastfeeding, or planning a pregnancy? *

If you are male, simply answer No.

Do you have, or have you ever had, any medical conditions that we should know about? *

Examples include:

• Diabetes (including prediabetes)
• Heart conditions
• High blood pressure
• High cholesterol
• Sleep apnoea
• Pancreatitis
• Gallbladder disease or gallstones
• Thyroid disease (including thyroid cancer)
• Kidney or liver disease
• Inflammatory bowel disease (Crohn's disease or ulcerative colitis)
• Mental health condition (e.g. depression, anxiety)
• Eating disorder
• Bariatric surgery
• Any medical conditions that may affect your weight

Do you have any known allergies, or have you ever had an allergic reaction to any weight loss medication? *

Are you currently taking any medication? *

This includes prescription medicines, medicines bought over the counter, supplements, and recreational drugs.

Have you previously taken any GLP-1 weight loss medication (such as Mounjaro, Wegovy, or Saxenda)? *

Please upload proof of your previous prescription or supply: *

Accepted documents include a prescription, dispensing label, dispatch note or receipt.
Your document must show:

• Your name or email address
• The medication name and dose
• A prescription, order or dispatch date

When did you start your treatment? *

What was your weight when you started your treatment? *

BMI: *

Have you experienced any side effects while taking this medication? *

Have you already had a video consultation with one of our clinicians for weight loss treatment? *

Is there any other information you think would be useful for our prescribing clinicians to know? *

This could include anything you haven't already mentioned that may be relevant to your treatment.

Do you consent to Reach Online Pharmacy contacting your GP if we consider this clinically appropriate? *

Providing your GP details helps us provide safe, coordinated care. This won't delay your assessment.

Declaration *

You're almost done. Please confirm that you agree with the following:

• I confirm that the information I have provided is accurate and complete to the best of my knowledge.
• I understand that my consultation will be reviewed by one of Reach Online Pharmacy's prescribing clinicians, and that submitting this consultation does not guarantee that treatment will be prescribed.
• I understand that prescribing decisions are based on the information I have provided, and that providing incorrect or incomplete information could affect my safety.
• I will contact Reach Online Pharmacy and inform my GP if I experience significant side effects, start any new medication, or if my medical conditions change during treatment.
• I will read the Patient Information Leaflet and the treatment information provided before starting my medication.
• I agree to the delivery terms and understand that medicines will be dispatched in line with storage and safety requirements.
• I agree to be contacted by Reach Online Pharmacy if further information or a follow-up consultation is required.