Assessment for Weight Loss

• Kindly provide a picture of the box with pharmacy label details visible.
• If you do not have the box please provide your current prescription, treatment notification or email showing approval and dispatch with details of
  • the medication name and strength 
  • your full name
  • the date
• To increase dose it must be dated within the last 8 weeks
• To continue on the same dose or lower it must be dated within the last 12 weeks

Once your order is approved it will be sent via Royal Mail Tracked signed for.

You agree to accept the responsibility of rearranging the delivery in the case of a missed or delayed delivery by Royal Mail and agree to deal with any missed or delayed deliveries directly with Royal Mail rather than with the pharmacy. For any deliveries received beyond 2 days of dispatch please contact us prior to opening to check the medication as it may be outside of the cold chain storage conditions which may effect the medication if it is bought in advance of use. Where this is due to missed deliveries due to you failing to accept delivery at the delivery address you agree that you will be liable for replacement and that the delivered medication will be disposed of via a local pharmacy. Where the delay is due to Royal Mail we will contact them to claim and either send replacement or refund accordingly but only once the claim has been approved by Royal Mail.

For cold-storage items such as Wegovy/Mounjaro you agree for us to send out via Royal Mail Tracked 24 with ice packs to maintain the cold chain temperature.

Please note - the stability of the medication cannot be fully guaranteed using this method due to factors out of the control of the pharmacy and the risk and liability is accepted by you as being your risk and liability.

• You declare that you have provided accurate and truthful answers to all the above questions.
• You will read the patient information leaflet provided with your medication before using your medication if prescribed. If you have any questions you can contact our support team or your GP.
• You will inform both us and your GP of your medication, if you experience any side effects of treatment, if you start any new medication or if your medical conditions change during treatment
• You acknowledge that our prescribers rely on your answers as truthful and honest to base their prescribing decisions accordingly, and that any incorrect or inaccurate information can result in serious and dangerous risks to your health- You understand that this questionnaire is part of a request to the prescriber and the final decision will rest with them.
• You understand that the prescribed treatment and medication is intended exclusively for your personal own use only.
• You consent to us informing your GP that you are going to start a new medicine to ensure continuity of your health records.
• You consent to us sharing consultation information with your GP or future/previous prescriber of this treatment and you give us permission to access your health records via your GP or other healthcare professional to verify any information if required (Required to ensured continuity of health records). We advise you also share this consultation information with your doctor for him/her to update your medical records.
• You understand that the information provided in this assessment will be reviewed by an independent pharmacist prescriber before your order is processed.
• You agree to consult with your healthcare provider before starting any new medication. 

You agree and understand:

• There may be an increased risk of pancreatitis, gall bladder problems and gallstones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek immediate medical advice.
• Injectable weight loss medications should not be used with any other weight loss medications.
• If you develop any lumps in the neck or a hoarse voice whilst taking this medication, you should stop the medication and immediately speak to your doctor
• Weight loss has been associated with a lowering of mood (depression), and if you are experiencing this, you should stop the medication and speak to your doctor.
• This medication should not be used by those that are trying to conceive or become pregnant. You must discontinue treatment at least 2 months before trying for a child.

• This medication may reduce the effectiveness of oral contraceptives and that you must use additional non-oral contraception methods (e.g. condoms) during your treatment

• I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.
• I understand that providing false information may result in my order being cancelled and may have serious health implications.
• I understand that once I have completed this consultation form, Pills2U will process my payment. However, please note that this does not guarantee treatment approval. If Pills2U determines that you are not suitable for treatment, you will be issued a refund.