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.

Did WeGovy help with your weight loss? List any side effects you experienced when taking the medication.

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.

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 staring 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?