Treatment Reorder Form

Please answer following questions...

If you're having difficulty answering these questions, don't hesitate to get in touch with us.

Have you been diagnosed with any new medical conditions since you completed your previous consultation with us.

This includes suspected cases or new symptoms.

Yes

Have you started any new medication since your last order?

Yes

Are you suffering from any side effects from this medication?

Yes

If you are reordering weight loss injections please enter your CURRENT weight and height to calculate your BMI?

Please select either Metric or Imperial measurements :

Metric (Meters and Kilograms)
Imperial (Feet and Pounds)

BMI Calculation :

If you are reordering weight loss injections, are you currently still taking the treatment i.e have you injected a dose within the last 14 days?

If no, please confirm:

Date you last injected?
Strength of last dose?
Reason for gap in treatment?

Yes

If you are reordering weight loss injections was your last treatment pen ordered from us?

If not, please email us evidence of your last treatment at verify@boltpharmacy.co.uk. This can be a photo of your medicine box with the dispensing label attached or a copy of your previous email confirmation from another provider.

Evidence SHOULD show:

Your name
Drug name
Drug strength
Date

Yes

Is there anything else you would like to tell us?

Yes

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