Consultation - Be Online Pharmacy

1 Acknowledgement

These questions are designed to help us understand how you will use the medication we may prescribe for you. Should you require assistance completing this form then please contact a member of our Customer Care team.

Please Note: If this is your first time taking this medication, you will only be allowed to order the initial strength for Mounjaro (2.5mg) and Wegovy (0.25mg). Following the initial dose, subsequent orders will be increased in strength using a stepwise approach.

Question 1:Do you acknowledge and affirm your agreement with the following?

1. You are between the ages of 18yrs to 75yrs and live in the United Kingdom.

2. You affirm that you are completing this consultation on your own behalf and are providing information to the best of your knowledge and ability.

3. You confirm that this treatment is solely for your own use and commit to utilising only one weight loss treatment concurrently.

4. You agree to read the Patient Information Leaflet supplied with the medication (if prescribed) and confirm that you are aware of the possible side effects of the medication.

5. You commit to fully disclosing any medical conditions, significant illnesses, surgical procedures, and current prescription medications.

6. You agree to your GP being informed of this purchase (if prescribed), and grant permission to our prescribers gaining access to your medical history, only when absolutely necessary.

7. You acknowledge and accept our Terms of Use, Terms of Sale, and Cancellation and Refund Policy, and you confirm that you have reviewed and understood our Privacy Policy.

Yes

2 About You and Your Health

These questions help us understand who you are and your current health.

Question 1:With which ethnic group do you primarily identify?

Why do we ask this? Optimal Body Mass Index (BMI) ranges may vary based on an individual's ethnic background.

Question 2:Are you currently pregnant, trying to conceive, or breastfeeding?

Yes

Question 3:What is your weight?

Weight

lbs

Stone

Pounds

Question 4:What is your height?

Height

ft/in

Feet

Inches

Question 5:Have you been diagnosed with diabetes?

Medications used to treat diabetes may affect how well the weight management medication in our program works in your body.

Question 8:Do you suffer from any other medical conditions?

Question 9:Are you currently taking any prescribed medication, over the counter medication or recreational drugs?

Question 10:Are you allergic to any medicines or other substances?

Question 11:Do you have a history of eating disorders or mental health conditions related to food or weight?

Question 12:Have you ever used any weight loss medication?

Question 13:Would you like to remain on your current dose or increase?

Question 14:We require evidence of your current dosage.

If you are requesting a higher strength as your starting dose, please provide proof of your current dosage by uploading an image of the label on the box or a copy of your most recent prescription. Without evidence of your previous dose, our prescriber may be unable to issue a higher dose as requested.

If you have not used any medicine before, skip this question and move onto the next.

Only images or pdf accepted

File #1

Question 15:Have you ever experienced any side effects when using weight loss medication?

Question 16:What is your target weight?

Weight

lbs

Stone

Pounds

Question 17:How often do you exercise for a minimum of 20 minutes or more?

Question 18:Do you consume alcohol?

If so, please indicate the no. of units per week. Use the following guide:
- Pint of lower-strength lager/beer/cider (ABV 3.6%) = 2 units
- Standard glass of red/white/rosé wine (175ml, ABV 12%) = 2.1 units
- Can of lager/beer/cider (440ml, ABV 5.5%) = 2.4 units
- Large (35ml) single measures of spirits are 1.4 units

Question 19:Do you smoke?

Yes

3 Image Verification

Question 1:Please upload a full length photo of yourself Infront of a mirror

We need this due to the new GPhC requirements for weight loss medication.

Only images are accepted.

Image #1

Question 2:Please upload a photo of you standing on a set of weighting scales.

We need to see evidence of your current weight due to the new GPhC regulations.

Only images are accepted.

Image #1

Acne

Contraceptives

Emergency Contraception

Erectile Dysfunction

Hair Loss

Menopause

Urinary Tract Infection (UTI)

Weight Loss

Assessment for Weight Loss

Weight Loss

1 Acknowledgement

Question 1:Do you acknowledge and affirm your agreement with the following?

2 About You and Your Health

Question 1:With which ethnic group do you primarily identify?

Question 2:Are you currently pregnant, trying to conceive, or breastfeeding?

Question 3:What is your weight?

Question 4:What is your height?

Question 5:Have you been diagnosed with diabetes?

Question 6:Do any of the following apply to you?

Question 7:Do any of the following apply to you?

Question 8:Do you suffer from any other medical conditions?

Is this a Critical Condition ?

Please describe below

Question 9:Are you currently taking any prescribed medication, over the counter medication or recreational drugs?

Please describe below

Question 10:Are you allergic to any medicines or other substances?

Please describe below

Question 11:Do you have a history of eating disorders or mental health conditions related to food or weight?

Please describe below

Question 12:Have you ever used any weight loss medication?

Please describe below

Question 13:Would you like to remain on your current dose or increase?

Question 14:We require evidence of your current dosage.

Question 15:Have you ever experienced any side effects when using weight loss medication?

Please explain below

Question 16:What is your target weight?

Question 17:How often do you exercise for a minimum of 20 minutes or more?

Question 18:Do you consume alcohol?

Question 19:Do you smoke?

3 Image Verification

Question 1:Please upload a full length photo of yourself Infront of a mirror

Question 2:Please upload a photo of you standing on a set of weighting scales.

Assessment Progress

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