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 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. *

Date of Birth *

What is your sex? *FemaleMale

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

I am pregnantI am breastfeedingI am trying to conceiveNone of the above

Please enter your current weight (kg) *

Please enter your current height (cm) *

Do you have or have you ever had an eating disorder such as anorexia or bulimia? *

Yes No

Are you currently taking weight loss medication or have used it in the past? *

YesNo

Please note that you will need to upload proof of your previous weight loss pen strength usage if you are planning to buy a dose higher than the starter dose.

What weight loss medication are you taking? *

MounjaroWegovyOzempicSaxendaOrlistatOther

What strength and how long have you been taking it for? *

Are you currently taking any prescription medications? *

Yes No

Please let us know what prescription medications you are taking. *

Do you have any medical conditions? *

Yes No

Please let us know your medical conditions: *

Do you have any allergies that you are aware of? *

Yes No

Please let us know what allergies you have. *

Do you have, or have you ever had, any of the following conditions? Select any that apply. *

Liver diseaseHeart failureDiabetesLiver diseaseGastroparesisKidney conditionHigh Blood PressureHigh Cholesterol LevelsSleep ApnoeaCurrent or Past History of Gallstones or Gallbladder Disease (not Gallbladder Removal)Current or Past PancreatitisCurrent or Past Endocrinological disordersDiabetic Retinopathy (Damage to back of eye caused by high sugar levels)Personal or Family history of MEDULLARY THYROID CARCINOMA (Thyroid Cancer)Personal history of multiple endocrine neoplasia syndrome type 2 (MED 2) - a disease where there are tumours in more than one gland in the bodyThyroid diseases other than Hyperthyroidism or HypothyroidismNone of the above

If you have a medical condition or are taking any medication that may contribute to weight gain, it's important to speak to your GP to determine if weight loss medication is suitable for you.

I understand *

Do you give consent for our prescriber to check your NHS summary care records if required? *

Yes No

To be prescribed from Be Medical Clinic, you must give our pharmacists consent to access your health records.

Would you like us to send this consultation to your GP? *

Yes No

GP practice name.

GP practice address.

Please confirm the following:

• All information I have provided is accurate and honest to enable Be Medical Clinic prescribers to make the best decision in regards to my health.

• Before taking my treatment, I will read, understand and follow the instructions in the patient information leaflet, including the risks and side effects.

• I am happy for the Be Medical Clinic clinicians to contact me if necessary to ensure suitability and safety.

• I will upload a full-length, clothed picture of myself after I have placed my order for the pharmacist to visually confirm my BMI.
  

• I am aware Be Medical Clinic can refuse or withdraw service without providing a reason (a refund will be issued).

• I will seek medical advice via a GP, NHS 111, walk-in centre, pharmacy and if necessary, A&E if I experience any adverse effects from my treatment.

• I will seek medical advice if my medical circumstances or condition changes.
  

I confirm all of the above. *

Please wait, files are uploading..

Submit