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Medical Assessment

Please state your height:

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Please state your weight:

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Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Please enter your body measurements:

  • Chest:;

    ?

  • Waist:;

    ?

  • Hips:;

    ?

  • Arms:;

    ?

  • Thighs:;

    ?

  • Calves: ;

    ?
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Have you ever been prescribed Ozempic (Semaglutide) or Rybelsus (Semaglutide) for weight loss?

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Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Have you been recommended any weight loss treatment by a healthcare professional?

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Phone 0207 867 3932

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Please upload a picture of yourself (full body shot from the front - you can omit your face). ?

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

What is your blood pressure range?





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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you suffer from any of the following? (tick all that applies to you):

  • Diabetes;
  • Mental health problems;
  • High Blood pressure;
  • High cholesterol;
  • Pancreatitis;
  • Liver or kidney problems;
  • Any other condition we should know about;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you suffer from thyroid problems or have a history of thyroid cancer in your family?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you taking any of the following (tick all that applies to you):

  • Warfarin or other oral anticoagulants ;
  • Insulin;
  • Ciclosporin;
  • Oral contraception;
  • Iodine salts and/or levothyroxine;
  • Amiodarone;
  • Medicines to treat HIV;
  • Acarbose (type 2 diabetes medication) ;
  • Medicines for depression, psychiatric disorders or anxiousness;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you currently taking any medication (including over the counter, prescription or recreational drugs) not mentioned above.?

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Have you ever suffered from an eating disorder, disordered eating or body dysmorphia?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you pregnant or breastfeeding or intending to become pregnant or start breastfeeding whilst taking medication?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you allergic to Semaglutide, Liraglutide, Orlistat, Bupropion or Naltrexon?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you smoke?

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you drink alcohol?

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

How many cups of tea/coffee you consume per day?

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Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

How many hours of sleep do you get on average per night?

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Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

How much exercise/activity do you get each week? (minutes/hours)

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

How many calories do you consume per day (if aware)?

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For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

How does your typical day looks like eating wise?

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For further information kindly contact our patient support team:

Phone 0207 867 3932

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What contributes to your excess weight (try to tick all that you think apply to you):












Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

What interventions have you previously tried to lose weight? Why would you say they didn’t work?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Please enter your GP's full name and surgery address so we can contact them to advise of the medication you have ordered.

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

I confirm that I have answered all the above questions truthfully.

  • Should I experience any changes in my medical history I will inform the clinic immediately. I understand that any medical treatment MUST be combined with exercise, reduced calorie diet for the best results;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you aware of the following?

  • Ozempic, Rybelsus and Victoza are prescribed off-label meaning they are not licensed for weight-loss;
  • if you experience any serious side effects, you need to contact your GP as soon as possible ;
  • the treatment cannot be continued if you gain weight 3 months after starting the treatment;
  • the treatment must be stopped once your BMI goes below 27;
  • the treatment should be combined with a nutritionally balanced, calorie-controlled diet and exercise;
  • with Orlistat (Xenical), the use of an additional contraceptive method is recommended to prevent possible failure or oral contraception that could occur in case of severe diarrhoea;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you agree to the following:

  • our prescriber might call you before issuing the prescription to ensure this treatment is safe and appropriate for you (Semaglutide and Liraglutide only) ;
  • you will read the patient information leaflet supplied with your medication;
  • the treatment is solely for your own use;
  • you give us permission to access you NHS Summary Care Record in order to identify you correctly, check your medical history and provide the best possible care;
  • you give us permission to contact your GP to inform them of your treatment (for Semaglutide and Liraglutide only);
  • you have answered all the above questions accurately and truthfully;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

I confirm that no guarantee for weightloss have been given and results will vary from individual to an individual. I am also aware that 1-2% of people won’t respond to the treatment but the reason for this in unknown and I accept the possibility.

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Please tick the boxes to confirm the following:

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Order before 15:00pm (Monday to Friday) for next day delivery