Free weight loss consultation | Victoria Central Pharmacy

Your details

The details of the person the consultation is for.

First name Last name Email Mobile number Date of birthThis service is for people aged 18 to 69. Sex at birth

Delivery address

Address line 1 Address line 2 optional Town or city Postcode

Height, weight and BMI

Treatment is usually for a BMI of 30 or more, or 27 to 29.9 with a weight-related medical problem. Your prescriber will confirm your weight on the video call.

Units

cm and kg feet and stone

Height (cm) Weight (kg)

Your BMI--

Do you have any of these weight-related medical problems?

Pre-diabetes High blood pressure / hypertension High cholesterol Obstructive sleep apnoea Heart disease or previous heart attack/stroke None of these

Your health

Some answers mean an online service isn't the safest option. If so, we'll tell you and suggest speaking to your GP.

Have you tried to lose weight before without success?

Yes No

What have you tried before?

Have you been diagnosed with diabetes?

Yes No

Have you ever had anorexia, bulimia or another eating disorder?

Yes No

Have you ever had pancreatitis or other pancreas problems?

Yes No

Do you have diabetic gastroparesis or severe stomach-emptying problems?

Yes No

Have you or a family member had medullary thyroid cancer or MEN2?

Yes No

Do you have, or have you had, any of these?

Heart condition Kidney problems Liver problems Inflammatory bowel disease Thyroid disease Gallbladder disease None of these

Medical conditions, regular medicines and allergies Anything else you'd like us to know? optional

Treatment and safety

You can change your mind on the video call. Your prescriber will recommend what suits you.

Which treatment are you most interested in?

Mounjaro Wegovy Wegovy tablets Foundayo tablets Orlistat Not sure

Are you taking any weight loss medicine at the moment?

Yes No

Important safety information

Get urgent medical advice if you have a severe allergic reaction, severe or persistent stomach pain, vomiting or diarrhoea that leaves you dehydrated, signs of pancreatitis or low blood sugar, eye problems, or any other severe or worrying reaction.

Do you understand these warning signs and when to get help?

Yes No

Will you take part in regular check-ins with our clinical team?

Yes No

If you choose an injection, are you happy for us to show you how to use it?

Yes No / not applicable

Check and send

Please confirm The information I've given is accurate and complete. I understand that completing this form doesn't guarantee treatment. I understand I'll need a video consultation with a prescriber, who decides whether treatment is right for me. I understand that if treatment isn't suitable, I'll be advised to speak to my GP or usual healthcare professional.