Weight Loss Treatment Reorder Form

1
Please confirm your legal name for prescription purposes* This field is required.
First Name
Last Name
2
Please confirm your email address* This field is required.This must match account email address
example@example.com
3
Calculate your current BMI* This field is required.Please enter your weight and height below - use the arrows to change the units if needed
4
Which weight loss medication are you currently using?
Mounjaro
Wegovy
5
What is your current dosage?* This field is required.
Please Select
Please Select
2.5 mg
5 mg
7.5 mg
10 mg
12.5 mg
15 mg
6
What is your current dosage?* This field is required.
Please Select
Please Select
0.25 mg
0.5 mg
1 mg
1.7 mg
2.4 mg
7
Please take a full-length photo of yourself using your device camera. This is optional, but we may request an updated photo at least once every 6 months for verification purposes.
8
On what date did you last inject your medication?* This field is required.
Please choose the date by clicking the calendar above
Day
Month
Year
9
Did you experience any side effects or have you had any change in your medical history?* This field is required.
Yes
No
10
Which of the following would you like to do?* This field is required.
Increase my dose
Stay on the same dose
Lower my dose
Change to a different medication
11
Please advise why you would like to lower your dose.
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Small
Ok
Ok
12
Please provide more details about the side effects you experienced or changes in your medical history* This field is required.
13
Please add any additional notes you feel would be helpful to the prescribing team. If you need any advice before ordering, please email support@swift-doctor.com.
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Large
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Ok
Ok
14
It is my responsibility to ensure my shipping address is correct and DPD/Royal Mail can safely deliver there. I have read all terms and conditions on the SwiftDoctor website.* This field is required.
I understand
15
Product Name
16
Variant_id
17
Collection name
18
Type
Should be Empty: