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.

Nutricia Fortisip Milkshake Style Chocolate Flavour - 200ml

• 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 Select an option Lose Weight Maintain Weight Medical Management
• 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.