Medical Questions

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.

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?

Please list all of your medical conditions

Do you understand and agree that:

• Orlistat will not work alone in aiding in reducing your weight. For the best results, this medication should be combined with a weight management plan (diet control), and regular, consistent exercise.
• Side effects (particularly oily stools), may be more likely if you have a high fat diet. Fat should take up no more than 30% of your calorie intake.
• If you take multivitamin supplements, these should be taken 2 hours after your Orlistat / Xenical dose, or at bedtime.

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:

• You or any of your family have a history of MTC
• You have MEN 2. This is a disease where people have tumours in more than one gland in their body
• You are allergic to liraglutide or any of the ingredients in Saxenda. Symptoms of a serious allergic reaction may include: swelling of your face, lips, tongue, or throat, fainting or feeling dizzy, very rapid heartbeat, problems breathing or swallowing, and severe rash or itching

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 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?

Have you been diagnosed with an underactive thyroid for which you take Levothyroxine?

Please provide more details

Do you suffer from depression or have you ever had any suicidal thoughts?

Please provide more details

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:

• You or any of your family have a history of MTC
• You have MEN 2. This is a disease where people have tumours in more than one gland in their body
• Diabetic retinopathy (Eye condition that can cause vision loss and blindness in people who have diabetes)
• You are allergic to Semaglutide or any of the ingredients in Wegovy.
• Symptoms of a serious allergic reaction may include: swelling of your face, lips, tongue, or throat, fainting or feeling dizzy, very rapid heartbeat, problems breathing or swallowing, and severe rash or itching

I am aware that I must:

• Take Wegovy  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
• Keep a good level of hydration to prevent suffering from dehydration

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.

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 muscle
Never 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?

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:

• You or any of your family have a history of MTC
• You have MEN 2. This is a disease where people have tumours in more than one gland in their body
• Diabetic retinopathy (Eye condition that can cause vision loss and blindness in people who have diabetes)
• You are allergic to Tirzepatide or any of the ingredients in Mounjaro.
• Symptoms of a serious allergic reaction may include: swelling of your face, lips, tongue, or throat, fainting or feeling dizzy, very rapid heartbeat, problems breathing or swallowing, and severe rash or itching
   

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?

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 become
or 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.

Do you require extra needles or a sharps bin?

You are given enough needles for your treatment complimentary.