Online Order Form

Please confirm the following:

I am 18 years old or above.
I am using this service on my own behalf and of my own free will, and any treatment or advice is for my sole use only.
I will inform my GP of any treatment I have received.
I understand my consultation will not be passed to the Be Medical Clinic team until I have submitted my online consultation.
I agree to Be Medical Clinic's terms & conditions and privacy policy.
I agree to be contacted by Be Medical Clinic.

I confirm and understand all of the above *

Please enter your first name. *

Please enter your last name. *

Please enter your email address. *

Please enter your phone number. *

Please enter your address details: *

Street address *

City *

State

Postcode *

Country *

Date of Birth *

Please enter your current weight (kg) *

Please enter your current height (cm) *

Do you suffer from prediabetes, diabetes, heart disease, high blood pressure, high cholesterol or obstructive sleep apnoea? *

YesNo

If you have type 2 diabetes, are you on any injections or tablets to control your blood sugar, other than metformin? *

YesNo

We are unable to supply this product to you. Please speak to your GP.

Have you experienced an allergic reaction to Wegovy, Mounjaro, Semaglutide, Saxenda or Liraglutide before? *

YesNo

This treatment is not suitable for you.

Have you ever suffered with an eating disorder? *

YesNo

This treatment is not suitable for you.

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

YesNo

This treatment is not suitable for you.

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

Acromegaly or any growth hormone problem
Chronic Malabsorption Syndrome
Cushings Syndrome
Gallbladder, Bile duct or Pancreas disease
Gastric surgery (bariatric surgery)
Heart Failure
Hypoglycaemia
Kidney Disease
Liver Disease
Pancreatitis
Severe gastrointestinal disease (e.g. inflammatory bowel disease, ulcerative colitis, Crohn's disease)
Type 1 Diabetes

YesNo

We are unable to supply this product to you. We suggest speaking to your GP or nurse about weight loss.

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

YesNo

We are unable to supply this product to you. Please speak to your GP.

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

YesNo

Are you taking any of the following medications?

Amiodarone
Carbamazepine
Ciclosporin
Clozapine
Digoxin
Fenfluramine
Lithium
Oral Methotrexate
Phenobarbital
Phenytoin
Somatrogon
Tacrolimus
Theophylline
Warfarin

YesNo

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

YesNo

Changes to eating patterns can affect the absorption of these medications, so your doctor may need to monitor your thyroid levels more closely. You should continue to take these medications according to your usual routine whilst using Saxenda, Wegovy or Mounjaro.

Have you taken injectable weight loss medication in the last 4 weeks? *

Yes No

Do you understand that you will be asked to provide evidence of a prescription with an alternative provider if the following applies to you: *

Yes No

This is your first order with Be Medical and you do not order the starter dose.
Your last order with Be Medical was more than 8 weeks ago and you wish to order a higher strength.
For guidance on selecting the correct dose, please contact us on WhatsApp here.

You must agree to this before continuing. If you need assistance with understanding which dose is appropriate for you, please contact us on WhatsApp here.

Do you agree to the following?

You will read the patient information leaflet supplied with your medication.
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use.
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

YesNo