Please enter your name

Please enter your email address.

Are you male or female?

What is your date of birth?

Please provide your age in cm

Please provide your weight in kg

Have you previously taken any medication(s) for weight loss?. If yes can you please mention the medication and for how long you took it.

How many days per week do you exercise 30 minutes or more?

How long have you had concerns about your body weight?

Have you been diagnosed with high blood pressure?

Have you been diagnosed with diabetes?. If yes please provide more information including all medications you take for this condition.

Do you have any other allergies? Please enter all types of allergies and intolerances. This includes allergies to drugs, anesthetic/numbing agents or foods such as soy or dairy.

Do you take any other medicines including prescription over-the-counter or recreational drugs?. If yes please provide the name and dose of all medicines you are currently take.

Are you comfortable using an injection pen?

Do you agree that all these questions are to better understand your recent state and propose the best treatment for you?

Please send us a message via email after filling and submitting the consultation form stating your name. Email: sales@ozempicpharmacy.store