Consultation – Believe Pharmacy

Belive pharma new

Do you agree and consent to the following:

I am over 18 years old and live in the UK.

I will be the sole user of any medication offered to me through this service.

I confirm all answers are provided by me and are completely truthful.

First Name

Last Name

What is your height & weight?

Metric

Imperial

neec any help

Height

Weight

Height

Numeric Field

feet

Numeric Field

inches

Weight

Numeric Field

stone

Numeric Field

pounds

What is your phone number?

What is Your Email Address ?

What is your date of birth?

What is your gender?

What is your ethnicity?

We ask this because ethnicity can influence how your BMI is evaluated. The listed options are based on guidelines from the government and the Office for National Statistics (ONS). Please select all that apply.

Where do you want us to deliver?

Address Line 1

Address Line 2

City

Region/Province

Post Code

Country

Now, we’ll go through some medical history questions to ensure this treatment is safe and suitable for you.
Please answer honestly and accurately.

Do you have any of the following health conditions?

Pre-diabetes

Type 2 Diabetes

Diabetes in pregnancy (gestational)

Polycystic ovary syndrome

High blood pressure

High cholesterol

Obstructive sleep apnoea (OSA)

Angina, Coronary heart disease (CHD) or Heart attack

Transient ischaemic attack (TIA) or Stroke

I do not have any of these health conditions

Have you been diagnosed or had surgery for a medical issue?

Fatty liver disease

Liver disease or Abnormal liver f

unction

Kidney disease or Abnormal kidney f

Irregular or Fast heart rate (Tachycardia)

Heart failure

Diabetic eye disease (Retinopathy)

I have not been diagnosed nor had surgery for a medical issue

Weight loss medications may occasionally cause an increased heart rate.

Are you under specialist care for your disease?

Yes

Please tell us more about your condition.

Do you have any of the following thyroid conditions?

Overactive thyroid (Hyperthyroidism)

Underactive thyroid (Hypothyroidism)

Thyroid cancer (you or your close family)

Multiple endocrine neoplasia syndrome type 2/MEN 2 (you or your close family)

Other thyroid disease

I do not have a thyroid condition

Multiple endocrine neoplasia syndrome warning

Please tell us what type of thyroid cancer do you or your close family have?

Medullary Thyroid Cancer

Papillary Thyroid Cancer

I don’t know

Weight loss medication may affect your thyroid medication.

OK, I understand

We advise having a blood test 3 months after starting weight loss medication.

Please tell us more about your thyroid condition

Do you currently have or have you ever had any of the following gut problems?

Gallstones or Gallbladder problems

Crohn's disease or Ulcerative colitis

Pancreatitis

Gastroparesis

I do not have any gut problems

What issues are there with your gallbladder?

No gallbladder symptoms in the last 12 months

Pain or other symptoms in the last 12 months

Awaiting gallbladder removal

Gallbladder removed within the last 3 months

Gallbladder removed more than 3 months ago

In the last 6 months, have you had symptoms or a flare up of your Crohn's or ulcerative colitis?

Yes

Warning about weight loss injections and side effects similar to Crohn's/colitis

OK, I understand

Have you ever been diagnosed with an eating disorder?

Anorexia Nervosa

Bulimia

Body Dysmorphic Disorder

No, I have never been diagnosed with an eating disorder

Do you have any other medical conditions that we haven't asked about yet?

Are you pregnant, or could you be pregnant?

Pregnant

Trying to get pregnant within the next 3 months

Unsure if pregnant

Given birth in the last 3 months

Pregnancy warning and testing recommendation

Are you breastfeeding?

Yes

Are you using any of these medications?

Diabetes medication

Insulin

Digoxin

Oral contraceptive pills

Theophylline or Uniphyllin

Lithium

Warfarin

Orlistat

Rybelsus® (Semaglutide Tablets)

Other

I am not taking any of these medications

What dose of Rybelsus® (semaglutide) are you taking?

3mg

7mg

14mg

Rybelsus® cannot be used alongside our prescribed weight loss treatments.

Mounjaro® may reduce the effectiveness of your contraceptive pill.

Do you use any other medication?

Do you have any of these allergies?

Semaglutide (Wegovy or Ozempic)

Tirzepatide (Mounjaro)

Benzyl alcohol

Disodium phosphate

Propylene glycol

Phenol

Hydrochloric acid

Sodium hydroxide

Penicillin

Grass, Tree, or Plant Pollen

House dust

Animals (cats, dogs, horses, etc.)

Gluten

Nuts

Lactose

Other

No allergies

Some medications we prescribe may contain small amounts of lactose, gluten or nut-based ingredients.

Please tell us what you are allergic to.

How can we help you today?

Every journey begins with a single step—let's take the first one towards a healthier you.

As you are new to weight loss injections, please choose the lowest possible dose of one medication.

OK, I understand

Consistency is key—stay on track with your weight loss journey.

When did you last administer your weight loss injection?

Which medication are you using to help you lose weight?

Which dose of Mounjaro® are you currently using?

2.5mg

5mg

7.5mg

10mg

12.5mg

15mg

Which dose of Wegovy® are you currently using?

0.25mg

0.5mg

1mg

1.7mg

2.4mg

15mg

Which dose of Ozempic® are you currently using?

0.25mg

0.5mg

1mg

2mg

Which dose of Saxenda® or liraglutide are you currently using

0.6mg

1.2mg

1.8mg

2.4mg

3mg

What is the name and dose of the weight loss medication you are currently using?

Where did you get your last dose weight loss medication from?

Believe Pharmacy

Somewhere else

As your last supply of medication was from another provider, please upload evidence.

Choose File

Are you experiencing any worrying or troublesome side effects from this weight loss medication?

Yes

What side effects are you having?

Nausea

Vomiting

Constipation

Diarrhoea

Abdominal discomfort

Severe abdominal pain

Other

Please tell us more about your vomiting, severe abdominal pain or other side effects

Getting back on track is the first step to reaching your goals.

When did you stop using your weight loss injection?

Which medication(s) did you use to help you lose weight?

Wegovy®

Mounjaro®

Ozempic®

Saxenda or Liraglutide®

Other

Did you previously get your weight loss injections from Believe Pharmacy?

Yes

How much did you weigh (in Kilograms, kg) when you started this treatment?

Why did you stop your medication?

Target weight reached

Side effects

Too expensive

Needed to take a break

Other

Tell us more about the side effects that caused you to stop using your medication.

Finding the right fit for your journey—let's explore your options.

Why do you want to change to another weight loss injection?

When did you first start using weight loss injections?

Which medication have you been using to help you lose weight?

Mounjaro®

Wegovy®

Ozempic®

Saxenda® or Liraglutide

Other

What is the name of the weight loss medication you are using?

Who started you on this weight loss injection?

Believe Pharmacy

Other option available

Please upload a clear image of your government-issued ID

Choose File

Please upload a clear, full-body front profile image

Choose File

Please upload a clear, full-body side profile image

Choose File

I confirm that I understand that only one type of weight loss medication should be used at a time.

OK, I understand

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Phone: +44 7751 231293