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Need help? 0121 772 5955
Need help? 0121 772 5955
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About You
Please provide your weight
Please provide your height
Do you smoke or drink?
Do you take any medication whether prescribed, over the counter, herbal/alternative or partake in any recreational drug use?
Do you have any allergies?
What is your blood pressure?
Have you been advised to avoid strenuous exercise?
Are you able to walk 3 miles or climb a set of stairs without pain in your chest?
Do you have any history of symptoms of anxiety or depression?

About your symptoms

Do you have any medical conditions or have any past medical history of note? E.g. surgery, chronic conditions such as PCOS, heart disease, diabetes
Do you have any of the following medical conditions (Please select all that apply.)
As mental health can be impacted by your body weight, please tell us about your mental health and wellbeing by selecting one of the following statements. (Please select all that apply)
Takeaway and fast food are typically high in fats, salt and other additives which can contribute to obesity, high blood pressure and increasing your risk of other conditions such as Heart disease. Select the option which applies best. (Please select all that apply)
Snacks can be a great way to get some much needed energy between meals. Unhealthy snacks such as crisps, chocolate or biscuits however can have a detrimental effect. Select the option which applies best.
Do you carry out any regular exercise? (Please select all that apply.)
Have you tried any weight loss medication before? (Please select all that apply)
Do you agree to inform us, your GP or seek appropriate medical attention if you suffer from any persistent hoarseness, sore throat, difficulty swallowing or any lumps in your neck?
Is there any particular treatment you are interested in / prefer?
a. Are you pregnant or planning a pregnancy?
Taking Semaglutide/Ozempic/Saxenda whilst trying to conceive or during pregnancy can cause a risk to the unborn foetus. It is important to stop such medications at least 2 months prior to trying to conceive or as soon as you discover you are pregnant. Please get in touch if you have any questions.
b. Are you breastfeeding?

GP Details

Would you like us to inform your GP of your treatment?
We recommend informing your GP surgery of any treatment that you are taking to keep your medical records relevant and up to date


Do you agree to the following?

You have answered all of the above questions accurately and truthfully. You understand our prescriber(s) will prescribe medication based on your responses and interactions with Twilight Pharmacy. Any incorrect responses or deliberate acts to misinform may be hazardous to your health.

You agree to the terms and conditions, privacy policy and terms of use.

You will familiarise yourself with the patient information leaflet included with your order and any other information relayed to you via other means including IM/E-mail/telephone.

You will contact us and inform your GP if you experience any side effects to treatment, if there are any changes to your medical history including starting any new medications or new diagnoses, or if your symptoms/medical conditions change in any way.

You understand completing a purchase does not guarantee supply of treatment; the final decision to prescribe lies with the prescriber with your best interests, health and appropriateness in mind.

You agree to the terms and conditions, privacy policy and terms of use.

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