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Start your weight loss journey
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20
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NewGen Pharmacy – Patient Consent Agreement
(Required)
You are completing this medical assessment for yourself and confirm that all information provided is accurate to the best of your knowledge. You agree to disclose any existing medical conditions, previous surgeries, and current prescription medications. You understand that only one weight management treatment may be prescribed at a time, and this will be determined by a licensed prescriber based on clinical suitability.
By submitting this questionnaire, you acknowledge that your responses are essential for safe and appropriate care. Providing incomplete or inaccurate information may pose serious risks to your health.
I agree.
Name
(Required)
First
Middle (If any)
Last
Email
(Required)
Phone
(Required)
(Required)
Full Address
City
Postcode
How old are you?
(Required)
Under 18
18 to 74
75 or over
Date of Birth
(Required)
DD slash MM slash YYYY
⚠ Please Note:
Persons at or under the age of
18
are
not eligible
for the weight loss treatment. Submissions from individuals below this age will
not go through.
⚠ Please Note:
Persons at or over the age of
75
are
not eligible
for the weight loss treatment. Submissions from individuals above this age will
not go through.
What is your ethnicity?
(Required)
Healthy BMI ranges vary based on ethnic background. Our clinicians will carefully assess your BMI and full medical history to determine the most suitable treatment, which may include off-label prescriptions when clinically appropriate.
Black (Caribbean, African)
Asian or Asian British
Mixed ethnicities
White
Other
What sex were you assigned at birth?
(Required)
Male
Female
Are you currently pregnant, trying to get pregnant, or breastfeeding?
(Required)
Yes
No
⚠ Please Note:
Women who are
pregnant
or
planning to have a child
are
not eligible
for the weight loss treatment. Submissions from individuals in this category will
not go through.
What is your current weight?
(Required)
Please enter your weight in kg.
What is your current height?
(Required)
Please enter your height in cm.
Have you been diagnosed with diabetes?
(Required)
Diabetes treatments can impact the way the medication included with our weight loss plan works.
I have diabetes and take medication for it
I have diabetes and it's diet-controlled
No, but there is history of diabetes in my family
I have pre-diabetes
I don't have diabetes
Please include a full list of all medication that you currently take.
(Required)
Do any of the following statements apply to you?
(Required)
These conditions can lead to serious complications when losing weight or taking weight loss medications.
I have chronic malabsorption syndrome (problems absorbing food)
I have cholestasis
I’m currently being treated for cancer
I have diabetic retinopathy
I have severe heart failure
I have a family history of thyroid cancer and/or I’ve had thyroid cancer
I have end-stage kidney disease
I have Multiple endocrine neoplasia type 2 (MEN2)
I have a history of pancreatitis
I have or have had an eating disorder such as bulimia, anorexia nervosa, or a binge eating disorder
I have had surgery or an operation to my thyroid
I have had a bariatric operation such as gastric band or sleeve surgery
None of these statements apply to me
Do any of the following statements apply to you?
(Required)
These conditions are often weight related and may be improved as a result of losing weight.
I have been diagnosed with a mental health condition such as depression or anxiety
My weight makes me anxious in social situations
I have joint pains and/or aches
I have osteoarthritis
I have GORD and/or indigestion
I have a heart/cardiovascular problem
I’ve been diagnosed with, or have a family history of, high blood pressure
I’ve been diagnosed with, or have a family history of, high cholesterol
I have fatty liver disease
I have sleep apnoea
I have asthma or COPD
I have erectile dysfunction
I have low testosterone
I have menopausal symptoms
I have polycystic ovary syndrome (PCOS)
None of these statements apply to me
Please tell us more about your mental health condition and how you manage it.
(Required)
Do you have any other medical conditions?
(Required)
Our clinicians need to know your full medical history to make sure our weight loss plan is safe for you.
Yes
No
Please list any other medical conditions you have.
(Required)
Our clinicians need to know your full medical history to make sure our weight loss plan is safe for you.
Have you ever taken any of the following medications to help you lose weight?
(Required)
Wegovy
Ozempic
Saxenda
Rybelsus
Mounjaro
Alli
Mysimba
I have never taken medication to lose weight
Other
Select All
Which weight loss medication(s) have you tried?
(Required)
What was your weight before starting your previous medication?
(Required)
Please enter your weight in kg or lbs (specify whether it's in kilograms or pounds)
When was your last dose?
(Required)
Less than 4 weeks ago
4-6 weeks ago
More than 6 weeks ago
What dose were you prescribed most recently?
(Required)
0.2mg
0.5mg
1mg
1.7mg
2.4mg
Other
If you want to continue, what dose would you like to continue with?
(Required)
A clinician will review your answers and select your dosage as appropriate. Price varies by dosage.
Increase my dose
Keep my dose
Decrease my dose
I don't want to continue with this medication
Have you experienced any side effects?
(Required)
Yes
No
Please tell us as much as you can about your side effects.
(Required)
The type, duration, severity and whether they have resolved.
Do you currently take any other medication or have any allergies?
(Required)
This includes prescribed medication, over-the-counter medication, and supplements. Select all that apply to you. It’s really important that we know about any medication you're taking so that we can make sure there are no interactions with your weight loss plan.
I’m on levothyroxine
I’m on warfarin
Other / I take more than one prescription medication
I don’t take any medication
I have allergies
Please include a full list of all medication that you currently take.
(Required)
Please list any allergies you have. It’s important that our clinicians are aware of any allergies you have to make sure the medication prescribed won’t be harmful.
(Required)
Would you like your GP to be informed of this consultation?
(Required)
To ensure we provide the best and safest service for you, we strongly encourage you to share your GP details so we can inform them about your treatment. If you are aware of your GP practice's email address, please enter them on the next screen.
Yes
No
Please enter your GP's Full Name
(Required)
Please enter your Gp's Email
(Required)
Please enter your GP's Postcode
(Required)
Please select your preferred weight loss treatment option below.
(Required)
Please note that your doctor will review your suitability and medical history prior to issuing a prescription, to ensure the selected treatment aligns with your individual needs and health requirements.
Tirzepatide
Semaglutide
Choose your prefered dosage.
(Required)
Doctor's consultation, prescription, and postal delivery along with four needles included.
Tirzepatide (2.5mg)
Tirzepatide (5mg)
Tirzepatide (7.5mg)
Tirzepatide (10mg)
Tirzepatide (12.5mg)
Tirzepatide (15mg)
Choose your prefered dosage.
(Required)
Doctor's consultation, prescription, and postal delivery along with four needles included.
Semaglutide (0.25mg)
Semaglutide (0.5mg)
Semaglutide (1mg)
Semaglutide (1.7mg)
Semaglutide (2.4mg)
What is your preferred method of contact?
Phone
Email
Both
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
