Once you have completed this consent form and uploaded the relevant evidence, one of our prescribers will review this and call you at your appointment time. They may wish to initiate a video conference with you to verify your identity – so please be prepared for this at your appointment time. The initial contact will however be by telephone.

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Name *

First

Last

Address: *

Date of birth – please note you must be over 18. Minors must have a face to face consultation with a registered doctor or pediatrician – call us on 0141 404 6545 option 1 for a referral. *

Email *

Best phone number to get you on *

Who is your primary care physician (GP) as we may need to talk to them about your request unless you opt out

I will contact my GP myself, you do not have my permission to contact my primary care providers about my care. *

• Do not contact my GP I will do this myself if needed

I am not currently pregnant, and will take (if appropriate) precautions against this during therapy with semaglutide. (NOTE: Our prescribers are not insured to prescribe to assist solely with fertility problems such as PCOS.) I will immediately stop therapy if I have a positive pregnancy test. *

• Agree
• Not applicable

Agree to the following statement: Semaglutide prescribing is a private service. £50 is the cost of an initial consultation and will include (if appropriate) a pysical prescription for 3 months supply. This does not include the cost of the actual medicine which must be paid seperately. After the first 3 month prescription is finished, I will need a review with my prescriber – and I am aware there is a further cost to this of £30 – in order to continue with this medication. Reviews thereafter will be 3 / 6 / 12 months as appropriate and will incur review fees on each occasion. *

• Tick here

You must agree to the following statement to continue: "I, nor anyone in my family (brother sisters parents grandparents children aunts uncles or cousins) have, to my knowledge, had medullary thyroid cancer (MTC)" – I understand that a history of MTC (which is a rare form of thyroid cancer) is a contraindication to being prescribed semaglutide." *

• Agree

I understand that there are product shortages with these products, so formally authorise the prescribers to use unlicensed medicines where necessary – these are products with the same drug in them, but may come from abroad, have a different name, or be intended for the treatment of a different condition. This will only happen when it is necessary to continue my therapy. *

• Agree

Please enter your weight in kilograms (kg) i.e. 64kg *

Please enter your height in metres (i.e. 1.72m) *

Please enter your abdominal measurements – taken at the widest part aroung your torso at belly button level, when standing, in Centimetres. i.e. 123cm *

I certify that the measurments submitted to our prescribers for assessment are honest & correct, taken with appropriate tools (such as a measuring tape and physical scale) – and I will continue to use the same measuring equipment during duration of my therapy. *

• Agree

I understand that therapy will be stopped if I do not lose 5% of my body weight within 3 months of being on the highest tolerated dose. Dosing starts at 0.25mg weekly and increases to 2.4mg weekly as tolerated. *

• Agree

I formally consent for Dickson Chemist to act on my behalf, to arrange a consultation for semaglutide weight loss products. I understand that this a PRIVATE non-NHS service which will attract cost for prescribing and dispensing. I confirm that I am not pregnant or breastfeeding and will take adequate precautions during my therapy period. I will upload the following items below: * Scan of paperwork showing my diagnosis * Scan of photographic ID * Any evidence of medications taken (i.e. a repeat form) *

• Agree

Medical evidence upload. 1) Photographic ID or selfie holding a household bill 2) Evidence of any medications you take (such as a repeat form), 3) A photograph of the readout from a scale showing the weight mentioned above. *

Click or drag files to this area to upload. You can upload up to 10 files.

Additional Comments / Tell us a little bit about yourself and your pertinent medical history. This is especially important if your BMI calculates to between 27 and 30 and you still want to proceed with therapy due to co-morbidities such as high blood pressure or heart disease. *

Submit