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(+91) 9876-543-210

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Info@MyChemist24.co.uk (+91) 9876-543-210

Pharmacy Details

Premise Registered Address:

The Owner name:

Superintendent Pharmacist Details:

A complaints procedure: Patient can post to our address, or contact via phone number 0161 938 7050 or email :

Pharmacy Details

Premise Registered Address:

The Owner name:

Superintendent Pharmacist Details:

A complaints procedure: Patient can post to our address, or contact via phone number 0161 938 7050 or email :

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Questions from our Pharmacist

As this is a Pharmacy Medicine, we need to ask you a few questions. These will help our Pharmacist ensure the product is right for you.

Are you currently using Weight Loss Pens?
Yes No
Please enter your age:
Sex at Birth
Male Female
Have you ever had a reaction to any medicine?
NHS Number (if available)
GP Name
GP Address incl. Post Code
Consent to share order with GP?
Yes No
Consent to check NCRS Record
Current Height (meters / feet)
Current Weight (kg / stones)
Do you have diabetes?
Yes No
Are you pregnant / planning pregnancy?
Yes No
Do you have any allergies?
Current Medications (Prescription or OTC)
Weight Goal
Goal Type
How would you like to achieve this goal?
Other Info
I agree to the Terms and Conditions and confirm all medical answers are accurate.
I will stop using this medicine and seek medical advice if unusual effects occur.
I confirm I am over 18 and agree to the Terms and Conditions of sale.

I agree to share records.

What is the sex of the person(s) using this medication?
Male Female
Is the medicine just for you?
Yes No
Age of intended user(s)
Do you have any known allergies?
Have you used this type of medicine before?
Yes No
Are you currently taking any other medication?
Is there anything else we should know?
I confirm all answers are accurate

Are you currently using Weight Loss Pens?
Yes No
Age
Sex at Birth
Male Female
GP Name
GP Address
Have you ever had a reaction to any medicine?
Please Enter your NHS Number (If Available)
Do you consent to share details of this order with your GP?
Yes No
I agree to share consent to check my NCRS Record?
What is your current height (meters/feet)?
What is your current weight (kg/stones)?
Have you been told that you have dyslipidaemia (e.g. high cholesterol)?
Have you been told that you suffer from sleep apnoea?
Yes No
Are you taking medication for blood pressure? If yes, name them
Do you have diabetes?
Yes No
Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Yes No
Are you breast-feeding?
Yes No
Do you have any allergies? If Yes, name them
Do you have any eating disorders, or have you had one in the past?
Yes No
Are you currently dependent on chronic opiates or going through withdrawal?
Yes No
Have you ever had a serious head injury or head trauma?
Yes No
Do you have chronic malabsorption syndrome?
Yes No
Have you been told you have Cholestasis?
Yes No
Do you have Gallstones?
Yes No
Do you have inflammatory bowel disease or gastroparesis?
Yes No
Do you have problems with your pancreas?
Yes No
Please enter your weight goal (kg/stones)
How would you like to achieve this goal?
Is there anything else that you would like to inform us?
I understand and give consent to the conditions of treatment.
I will stop use and seek help if I experience unusual side effects.
The medicine is solely for my use and I will read the leaflet.
I am over 18 and agree to Terms and Conditions.