Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Are you currently:
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Do you currently have or have you had any medical problems or surgeries/operations, for example:
Please provide more details
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you have any allergies to medications or any other substances?
Please list everything you are allergic to and what symptoms you experience.
Do you take or use any recreational drugs?
Please list everything you use. This information will not be shared with anyone apart from our prescribers.
What is your blood pressure?
What is your ethnicity?
(This will help our prescribers gain a better idea about your risk in relation to your weight)
Please provide more information
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Please ensure you update your weight each time when re-ordering. Failure to do so could result in a rejection of your order.
What is your age?
Please enter your height and weight
What is your height (cm)?
What is your height (feet)?
What is your weight (kg)?
What is your weight (stone/pounds)?
BMI
What is your target weight (stone/pounds)? Please ensure you update your current weight above with each order.
What is your target weight (kg)? Please ensure you update your current weight above with each order.
**Are you currently using any weight loss medication? (including Mounjaro/Wegovy, purchased from ourselves or elsewhere)**
Did Saxenda help with your weight loss? List any side effects you experienced when taking the medication.
Did Orlistat help with your weight loss? List any side effects you experienced when taking the medication.
What dose of Mounjaro are you currently taking?
Did Mounjaro help with your weight loss? List any side effects you experienced when taking the medication.
If your last supply of medication was from another provider, please upload evidence. Evidence can be either: your Mounjaro box with a pharmacy/dispensary label, a letter from your previous Pharmacy/GP, a copy of your previous prescription or a screenshot of your previous order. Your name, the name of the medication and the strength should be clearly visible. Without the correct evidence your order will not be approved. If your previous supply was from ourselves, you do not need to upload evidence.
*You can email this to us after the assessment if unable to upload to [email protected]*
What dose of Wegovy are you currently taking?
Did WeGovy help with your weight loss? List any side effects you experienced when taking the medication.
If your last supply of medication was from another provider, please upload evidence. Evidence can be either: your Wegovy or Ozempic box with a pharmacy/dispensary label, a letter from your previous Pharmacy/GP or a copy of your previous prescription. Your name, the name of the medication and the strength should be clearly visible. Without the correct evidence your order will not be approved. If your previous supply was from ourselves, you do not need to upload evidence.
*You can email this to us after the assessment if unable to upload*
What weight loss medication are you taking and have you experienced any side effects with this medication?
Do you have a history of any kidney or liver conditions?
Please list all of your medical conditions
People with weight-related medical conditions may be prescribed weight loss medicines at a lower BMI than other patients, if suitable. Please let us know if you have any of the following weight-related conditions:
Have you been diagnosed with any of the following conditions?
If applicable, please ensure that you have listed all of your medical conditions and medications that you take at the start of this assessment. Failure to do so will likely result in your order being rejected or delayed.
Please tell us how many calories you consume on a daily basis:
How many times per week do you consume take-away food?
How often do you consume snack foods (e.g crisps, biscuits, chocolate, ice cream)?
How much exercise do you do per week?
Please upload a full length picture of yourself
**Optional Question - Please be aware, you can still proceed with the consultation without uploading a photo, it is not compulsory however it will help us in making an informed clinical decision**
Please select the medication you plan on making an order for and confirm the relevant acknowledgements:
Do you understand and agree that:
I am aware and understand that Saxenda can cause side-effects and I will inform my doctor or practitioner and stop taking Saxenda if I experience any of the following:
Possible thyroid tumours, including cancer. Tell your health care professional if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rats and mice, Saxenda® and medicines that work like Saxenda® caused thyroid tumours, including thyroid cancer. It is not known if Saxenda® will cause thyroid tumours or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people. Do not use Saxenda® if you or any of your family have ever had MTC, or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
I am aware that I should not use Saxenda and will not attempt to make an order if any of the following applies:
I am aware that this treatment, should be taken in conjunction with a well balanced, calorie controlled/nutritional diet. No more than 30% of my calories should come from fat and my diet should generally be rich in fruit and vegetables.
I confirm that I will ensure to keep good levels of hydration by drinking 8-11 cups of liquid per day (2.7L) to ensure that I do not become dehydrated
I understand I should contact my own GP if I have not managed to achieve a 5% loss of my body weight within a 12 week period and I agree to have a review with my GP after taking this medication for 12 weeks, to ensure the medication is still suitable and if further treatment is required
I confirm that Saxenda must be administered using the following method:
Inject your dose of Saxenda® under the skin (subcutaneous injection) in your stomach area (abdomen), upper leg (thigh), or upper arm, as instructed by your health care provider. Do not inject into a vein or muscle
Never share your Saxenda® pen or needles with another person. You may give an infection to them, or get an infection from them.
Do not use the same needle more than once between each dose
You agree that you will store Saxenda pen in a refrigerator (between 2°C to 8°C) once you receive your delivery. If you do not do this, Cloud Pharmacy cannot and will not be held responsible for the medication not functioning as intended. Once you start using the pen, you can keep the pen for 1 month when stored at a temperature below 30°C or in a refrigerator.
I understand that if I place an order for Saxenda after 3.30pm on a Friday, Cloud Pharmacy will not ship my order until the following Monday due to the medication being a temperature/time critical item. This applies even if you choose the 'next day delivery' option on the checkout page. This may change around public holidays so please look out for your delivery confirmation email.
Saxenda is exempt from free delivery as we ship the injections via Royal Mail Tracked 24 to ensure the product arrives in a timely manner and does not spoil. However, we highly recommend you select the Royal Mail Guaranteed Service or DPD at the checkout stage.
Saxenda is licensed in the EU and imported into the UK due to the current shortage in the UK market.
I accept that the use of this product is off-license and I am using this at my own risk and that the Cloud Pharmacy team are here to help me on my weight loss journey
Do you require needles or a sharps bin?
Please click the following links to add them to your basket:
Please note that needles do not come with this order and are required for use with Saxenda pens.
Have you been diagnosed with an underactive thyroid for which you take Levothyroxine?
Do you suffer from depression or have you ever had any suicidal thoughts?
Acute pancreatitis is an uncommon side effect of Wegovy treatment. Patients should look out for the signs of pancreatitis whilst using Wegovy. These include severe, persistent abdominal pain that radiates to the back, tenderness when touching the abdomen, rapid heartbeat, fever, nausea and vomiting. If you suspect pancreatitis, stop using Wegovy and see your GP.
Wegovy is a ONCE weekly injection
If you have previously used Saxenda, you must wait 7 days after your last Saxenda injection before starting Wegovy.
I am aware that Wegovy can cause the following side effects:
Possible thyroid tumours, including cancer. Tell your health care professional if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rats and mice, Wegovy and medicines that work like Wegovy caused thyroid tumours, including thyroid cancer. It is not known if Wegovy will cause thyroid tumours or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people. Do not use Wegovy if you or any of your family have ever had MTC, or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
I am aware I should not use Wegovy if any of the following applies:
I am aware that I must:
I understand I should contact my own GP if I have not managed to achieve a 5% loss of my body weight within a 12 week period.
I agree to have a review with my GP after taking this medication for 12 weeks, to ensure the medication is still suitable and if further treatment is required?
I will store Wegovy in a refrigerator (2°C to 8°C) on receipt of delivery. If you do not do this, Cloud Pharmacy cannot be held responsible for the medication not functioning as intended. Once you start using the pen, you can keep the pen for 1 month when stored at a temperature below 30°C or in a refrigerator.
I understand that if I place an order for Wegovy after 3.30pm on a Friday, Cloud Pharmacy will not ship my order until the following Monday due to the medication being a temperature/time critical item. This applies even if you choose the 'next day delivery' option on the checkout page. This may change around public holidays so please look out for your delivery confirmation email.
Wegovy is exempt from free delivery as we ship the injections via Royal Mail Tracked 24 to ensure the product arrives in a timely manner and does not spoil. However, we highly recommend you select the Royal Mail Guaranteed Service or DPD at the checkout stage.
I confirm I am aware Wegovy must be administered by using the following method:
Inject your dose of Wegovy under the skin (subcutaneous injection) in your stomach area (abdomen), upper leg (thigh), or upper arm, as instructed by your health care provider. Do not inject into a vein or muscleNever share your Wegovy pen or needles with another person. You may give an infection to them, or get an infection from them.
Do you require a sharps bin?
Please click the following link to add one to your basket:
I understand that if I am using Mounjaro for the first time I must start with 2.5mg dose.
If you order a higher dose and we have NO record of you starting from 2.5mg, your order will be cancelled, unless evidence can be provided.
Acute pancreatitis is an uncommon side effect of Mounjaro treatment. Patients should look out for the signs of pancreatitis whilst using Mounjaro.
These include severe, persistent abdominal pain that radiates to the back, tenderness when touching the abdomen, rapid heartbeat, fever, nausea and vomiting. If you suspect pancreatitis, stop using Mounjaro and see your GP.
Mounjaro is a ONCE weekly injection.
If you have previously used Saxenda or Wegovy 0.25mg or 0.5mg, you must wait 2 weeks after your last Saxenda or Wegovy injection before starting Mounjaro. If you have used 1mg, 2.7mg or 2.4mg you must wait 4 weeks before starting Mounjaro.
I am aware that Mounjaro can cause the following side effects:
Possible thyroid tumours, including cancer. Tell your health care professional if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rats and mice, Mounjaro and medicines that work like Mounjaro caused thyroid tumours, including thyroid cancer. It is not known if Mounjaro will cause thyroid tumours or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people. Do not use Mounjaro if you or any of your family have ever had MTC, or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
I am aware I should not use Mounjaro if any of the following applies:
Are you aware this treatment, should be taken in conjunction with a well balanced, calorie controlled/nutritional diet. It should contain 30% of calories from fat and be rich in fruit and vegetables?
For any effective weight loss treatment you must have a well balanced, calorie controlled/nutritional diet. This should contain 30% of calories from fat and be rich in fruit and vegetables.
Are you aware it is advised to keep a good level of hydration, to avoid suffering from dehydration?
This medicine should not be used during pregnancy, as it is not known if it may affect your unborn child. Therefore, it is recommended to use contraception while using this medicine, switch from oral to non-oral contraceptives for the first four weeks when Mounjaro is initiated. If you wish to become pregnant, you should stop using this medicine at least two months in advance. If you becomeor are pregnant, think you may be pregnant or are planning to have a baby when using this medicine, talk to your doctor straight away, as your treatment will need to be stopped.
You should not use this medicine if you are breast-feeding, as it is unknown if it passes into breast milk.
Are you currently using hormonal contraception?
I understand that I must use an additional barrier method of contraception when starting Mounjaro or for 4 weeks when increasing my dose, as Mounjaro can reduce the effectiveness of my hormonal contraception.
I confirm I am aware Mounjaro must be administered by using the following method:
Inject your dose of Mounjaro under the skin (subcutaneous injection) in your stomach area (abdomen), upper leg (thigh), or upper arm, as instructed by your health care provider. Do not inject into a vein or muscle
Never share your Mounjaro pen or needles with another person. You may give an infection to them, or get an infection from them.
You will store Mounjaro in a refrigerator (2°C to 8°C) on receipt of delivery. If you do not do this, Cloud Pharmacy cannot be held responsible for the medication not functioning as intended. Once you start using the pen, we recommend storing in a refrigerator or you can keep the pen for 21 days when stored at a temperature below 30°C.
Mounjaro is exempt from free delivery as we ship the injections via Royal Mail Tracked 24 to ensure the product arrives in a timely manner and does not spoil. However, we highly recommend you select the Royal Mail Guaranteed Service or DPD at the checkout stage.
Do you require extra needles or a sharps bin?
You are given enough needles for your treatment complimentary.
I must accept the first delivery attempt on any temperature-controlled medicines such as Saxenda, Wegovy or Mounjaro as Cloud Pharmacy are not liable for any deliveries missed or address errors.
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
We use cookies to give you the best online experience. By using our website you agree to our use of cookies in accordance with our cookie policy.