Answer a few quick questions to see your eligible treatments Returning Patient? Sign in to reorder using your saved assessment. Sign In Weight Assessment Measurement Units MetricImperial What is your weight? (kg) What is your target weight? (kg) What is your height? (cm) What is your weight? What is your target weight? What is your height? Your BMI is About You What is your ethnicity? --Select--Black, African, Caribbean or Black British – includes any Black backgroundAsian or Asian British – e.g. Bangladeshi, Chinese, Indian, Japanese, or any other Asian backgroundMiddle Eastern – e.g. Arab, Iranian, or any other Middle Eastern backgroundMixed or multiple ethnic groups – e.g. White and Black Caribbean, or Black British and ChineseWhite – e.g. British, Irish, or White Irish Traveller backgroundOther ethnic group – please specifyPrefer not to say Is this your first time using the C Goode Pharmacy website for weight loss treatment? YesNo Are you between the ages of 18 and 74? YesNo What is your blood pressure? --Select--Normal – Between 90/60 – 150/100High – Above 150/100Low – Below 90/60 Do you have any allergies? YesNo Are you pregnant or breastfeeding? YesNo Do you have diabetes or prediabetes? YesNo Have you been told that you have high blood pressure? YesNo Have you been told that you have high cholesterol? YesNo Have you ever had any problems with your kidneys or liver? YesNo Have you ever been diagnosed with heart failure? YesNo Have you ever had pancreatitis? YesNo Do you have epilepsy or a history of seizures? YesNo Have you ever been diagnosed with an eating disorder? YesNo Do you have inflammatory bowel disease or gastroparesis? YesNo Have you ever been diagnosed with a mental health disorder? YesNo Do you have polycystic ovarian syndrome or Cushing’s syndrome? YesNo Do you currently have any problems with your gall bladder? YesNo If you have any other medical conditions, please give details below: Medications Have you used injectable weight-loss medication in the past 4 weeks? YesNo Are you currently taking any other medication, or have you recently completed a course of medication? YesNo (After fill medication name, strength and dose click on "Add" button to add in list) Medication Name Strength How many do you take a day? AddRemove Current Medications List Do you give us permission to inform your NHS surgery about this prescription? YesNo Please enter GP surgery information Surgery Name Street Address City/Town Country Postcode ADDITIONAL NOTES FOR THE PRESCRIBER Is there anything you would like the Pharmacist to know? (Include details such as upcoming travel or personal circumstances that may affect your treatment.) Consent & Acknowledgement By continuing, you confirm that you: Will read the information leaflet provided with your medicine before use. Will let us and your GP know if you develop side effects, start any new medicines, or if your health changes during treatment. Understand this prescription is for your own use only. Have answered all questions honestly and accurately. You accept that our Pharmacists rely on your responses, and that giving incorrect details could put your health at risk. YesNo Do you understand that GLP-1 injectable weight-loss medication (such as Mounjaro and Wegovy) may reduce the effectiveness of oral contraceptives and that you must use additional non-oral contraception methods (e.g. condoms) during your treatment? YesNo Accept that this treatment must not be used if you are trying to conceive, or within two months of planning a pregnancy. YesNo Understand there may be a risk of pancreatitis, gallbladder issues, or gallstones. You will seek medical advice immediately if you develop abdominal pain. YesNo Do you acknowledge that injectable weight-loss medication must not be taken together with any other weight-loss treatments? YesNo Do you acknowledge that the development of neck lumps or voice changes (such as hoarseness) while on this medication requires you to discontinue treatment and seek medical advice? YesNo Do you understand that weight-loss treatments may affect mood, and that if you experience low mood, depression, or thoughts of self-harm, you should stop treatment and speak to your doctor? YesNo I confirm that I am at least 18 years old and that I agree to the Terms and Conditions. I consent to C. Goode Pharmacy accessing my NHS Summary Care Record to verify my identity, review my health information, and notify my GP about the treatment provided. Previous Next Personal Details First Name Last Name Your Email Phone Number Date of Birth GenderMaleFemaleOther Password Confirm Password Address Line 1 Address Line 2 City Postcode NHS Number I confirm that I am registering with C. Goode Pharmacy to begin my weight loss treatment and agree to proceed with the programme. I confirm that I have read, understood, and accept the Terms and Conditions and Privacy Policy. Procced Previous Next Estimated time to complete 3 minutes Security Confidential & Secure Our prescribers will review your details in complete confidence Your medication will be delivered in plain unlabelled packaging All data is securely encrypted with 128bit SSL Your Pharmacist Melika KalantariPharmacist GPhC (2049338)
