ID Form - PPRX

ID Consultation Form

Complete this ID form to confirm identification for weight loss products. This form will be reviewed by a UK-registered prescriber before any treatment is approved. You may be required to provide additional verification, such as a video consultation or GP notification. Please ensure all information is accurate, as this will affect your treatment eligibility. Your data is encrypted and handled in accordance with GPhC and GDPR regulations. If you have any questions, contact our pharmacy team before proceeding 0208 191 3034.

Name(Required)

First Last

Date of Birth(Required)

One form of ID (passport or driving license)(Required)

Accepted file types: jpg, jpeg, png, gif.

A clear full length photo of yourself (Front, including face)(Required)

Accepted file types: jpg, jpeg, png, gif.

A fully clothed picture is acceptable as long as the picture is a full length front profile picture.

A clear full length photo of yourself (Sideview) (Required)

Accepted file types: jpg, jpeg, png, gif.

A fully clothed picture is acceptable as long as the picture is a full length side profile picture.

If you have taken this medication previously, a photo of a prescription or medication packaging with your name and details

Accepted file types: jpg, jpeg, png, gif.

Anything else you would like to tell us?

Weight Loss Treatments

4 Week Dose, Special Next Day Delivery, Pharmacy and Prescriber Support.

*Please complete consultation form before purchase.

Register/Login

ID Consultation Form

Weight Loss Treatments

From £215

From £170