Answer a few quick and easy questions from our pharmacists to see what treatments you’re eligible for. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Weight AssessmentWeight AssessmentEnter Your Height:cmEnter your WeightkgAbout YouAre you between the ages of 18 and 74? Yes No If you have type 2 diabetes, are you on any injections or tablets to control your blood sugar, other than metformin? Yes No Have you experienced an allergic reaction to Wegovy, Mounjaro, Semaglutide, Saxenda or Liraglutide before? Yes No Have you ever suffered with an eating disorder? Yes No Are you pregnant, breastfeeding, or trying to conceive? Yes No 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 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 Yes No Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome? Yes No MedicationAre you currently taking any medication (including over the counter, prescription or recreational drugs)? Yes No Are you taking steroids or medication to treat your thyroid? Yes No 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: This is your first order of with HealthLink Clinic and you do not order the starter dose Your last order with HealthLink Clinic was more than 8 weeks ago and you wish to order a higher strength Do you understand that you will be asked to provide evidence of a prescription with an alternative provider if the following applies to you: This is your first order of with HealthLink Clinic and you do not order the starter dose Your last order with HealthLink Clinic was more than 8 weeks ago and you wish to order a higher strength. Yes No AgreementDo 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. 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. Yes No 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? Yes No Do you understand that this medication should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child? Yes No Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice? Yes No Do you understand that injectable weight loss medications should not be used with other weight loss medications? Yes No Do you understand if you develop any lumps in the neck or hoarse voice whilst taking this medication, you should stop the medication and speak to your doctor? Yes No Both weight loss and injectable weight loss treatment has been associated with a lowering of mood. If you are experiencing this (depression, thoughts of self harm or other mental health issues), do you understand you should stop treatment and speak to your doctor? Yes No Do you consent to share your details with your GP? * Yes No I agree to the Terms and Conditions and I confirm that I am over 18. *I agree to the Terms and Conditions and I confirm that I am over 18. *I agree to my prescription being issued faster via the assisted prescribing service, if eligible. *I agree to my prescription being issued faster via the assisted prescribing service, if eligible. *Comment or MessageSubmit
