Simple Online Pharmacy

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Please note: Saxenda supplies/availability in the UK is intermittent and irregular. Please keep this in mind when starting treatment.

1About you

Are you aged between 18-74? *

NoYes

What was your sex registered at birth? (i.e. your biological sex) *

Are you pregnant, breastfeeding or planning to try conceiving (imminently or in the near future)? *

NoYes

So we can calculate your BMI, please enter your height and weight (It's really important you give us an accurate up-to-date measurement. You may be asked to provide evidence of your current weight) *

Height (cm) *

Please ensure you enter your correct height as this can't be changed for future orders

Weight (kg) *

Height (feet) *

Weight (stone/pounds) *

BMI

2Your medical history

Do you have any of the following conditions? *

Do you currently have, or have you ever had problems with your gallbladder or bile duct? *

NoYes

Could you please provide more information about your gallbladder issues? *

When did you have surgery to remove your gallbladder? *

Please provide more information *

Do you have diabetes? *

Are you taking any of the following medication? *

GLP-1 receptor agonists, not including Saxenda (e.g. dulaglutide, semaglutide, exenatide)SGLT-2 inhibitors (e.g. canagliflozin, dapagliflozin, emapgliflozin)Sulfonylureas (e.g. gliclazide, glimepiride, glipizide)Not applicable

If suitable, people with certain medical conditions may be prescribed weight loss medicines at a lower BMI than other patients.

Do you have any weight-related conditions such as high blood pressure, type 2 diabetes, obstructive sleep apnoea, non-alcoholic fatty liver disease, non-alcoholic steatohepatitis (NASH) or high cholesterol? *

NoYes

Please provide more information below: *

Have you ever made yourself sick (vomit) to control your shape or to lose weight? *

NoYes

In the last year, have you ever taken laxative medication in order to lose weight? *

NoYes

Do you worry that you have lost control over how much you eat? (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time?) *

NoYes

Would you say that food or image dominates your life *

Do you ever eat in secret? *

NoYes

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? (You do not need to mention any medicines already declared in previous sections, nor any weight loss medicines- we'll ask about them specifically below) *

NoYes

Please provide more details *

Do you have any known allergies? *

NoYes

Please provide more details *

Have you had any surgery in the last 3 months? *

NoYes

Please provide more details: *

Have you ever or do you currently experience an eating disorder (e.g. binge eating disorder, anorexia, or bulimia)? *

NoYes

How much exercise do you undertake each week? *

In order to get the best weight loss results with Saxenda, you should use it in conjunction with regular exercise.

Are you CURRENTLY using any weight loss medicines? i.e. have used in the last 2 weeks. (including Saxenda, Mounjaro, Wegovy, Ozempic, Orlistat, Xenical, Other) *

NoYes

You should only use one weight loss medication at a time. If you are currently using a once-per-week injectable such as Wegovy/Ozempic or Mounjaro you should wait at least 4 weeks before starting Saxenda. Please tick to confirm that you understand: *

Confirm

Did you obtain your last supply of weight loss medicine from us at Simple? *

Which medication have you been using? *

How long have you been using it? *

What was your BMI (or weight) when you started this medication? *

Have you EVER used any weight loss medicines in the past? (purchased from ourselves at Simple OR elsewhere, including Orlistat, Saxenda, Wegovy, Ozempic or others) *

NoYes

Which medication have you been using? *

What was your BMI (or weight) when you started this medication? *

How long have you been using it? *

Is there any other information you feel would be useful for our clinicians to know about? *

NoYes

Please provide more information: *

After completion of the assessment, you may be sent a link to upload realtime photographs of yourself to confirm suitability for treatment. Please tick to confirm that you understand. *

Confirm

3Acknowledgements

In the interest of patient safety, our doctors need your GP details in order to prescribe this medication for you. We will notify them of the supply. You will not be able to complete this consultation unless you provide these details. Please confirm that you understand. *

NoYes

Please enter your postcode to display your local GP's

You must provide your GP details before you can proceed

Please enter your GP’s name and surgery address. Please also enter their email address and fax number, if you know it.

You can find your GP surgery information details below

Please enter your GP surgery name *

Please enter your GP surgery address and post code *

Please enter your GP surgery email

I confirm I am aware Saxenda must be administered by 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

Confirm

You will store Saxenda in a refrigerator (2°C to 8°C) on receipt of delivery. If you do not do this, Simple Online 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. *

Confirm

Whilst using Saxenda, you confirm that you will:

Tell your health care professional if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath.
Drink plenty of fluids to avoid dehydration.

Confirm

If I have not lost at least 5% of my initial body weight after 12 weeks at the maximum daily dose of 3mg, I understand that I should discontinue treatment with Saxenda *

Confirm

Please tick to confirm that:

This treatment is for me, and I consent to this treatment.
I confirm that all the above information is truthful and accurate.
I agree to inform SOP of any change to my health as soon as possible, as I understand this could impact the suitability of the medication I am being prescribed.
If Saxenda does not help me realise my weight loss aims, I will consult my GP for further advice.
I understand that if I place an order for Saxenda after 12pm on a Saturday, Simple Online Pharmacy will not ship my order until Monday (unless a public holiday) 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.
I understand that if I experience any troublesome side effects from Saxenda, I can contact Simple Online Pharmacy, my GP, or another healthcare professional for advice. I confirm that I will read about the side effects in the Patient Information Leaflet.
I agree to the Simple Online Pharmacy terms and conditions.

Confirm

This questionnaire forms the basis of your weight loss consultation today. We need you to be honest with your answers including your weight and any current medication you are on. This allows our doctors to safely prescribe medication and offer accurate advice.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

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Assessment Progress

NHS Prescriptions made Simple

Assessment

1About you

2Your medical history

3Acknowledgements