Weight Loss Treatment Form

  • Home
  • Weight Loss Treatment Form
Please enable JavaScript in your browser to complete this form.

Patient Consent Agreement

You are completing this consultation for yourself and to the best of your knowledge. You will disclose any medical conditions, serious illnesses or operations you have had. You will disclose any prescription medications you are currently taking and agree to use only use one weight loss treatment at a time. You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy. Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life-threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation

PATIENT CONSENT AGREEMENT

Personal Information

What is your ethnicity?

Healthy BMI ranges vary based on ethnic background. Our clinicians will carefully assess your BMI and full medical history to recommend the most suitable treatment. This may include off-label prescriptions when clinically appropriate

What is your ethnicity?
What sex were you assigned at birth?
Are you currently pregnant, trying to get pregnant, or breastfeeding?

Have you been diagnosed with diabetes?

Diabetes treatments can impact the way the medication included with our weight loss plan works.

Have you been diagnosed with diabetes?

Do any of the following statements apply to you?

These conditions can lead to serious complications when losing weight or taking weight loss medications.

Do any of the following statements apply to you?

Do any of the following statements apply to you?

These conditions are often weight related and may be improved as a result of losing weight.he following statements apply to you?

Do any of the following statements apply to you?
Please tell us more about your mental health condition and how you manage it
Do you have any other medical conditions?
Our clinicians need to know your full medical history to make sure our weight loss plan is safe for you.
These conditions can lead to serious complications when losing weight or taking weight loss medications.
Have you ever taken any of the following medications to help you lose weight?
These conditions can lead to serious complications when losing weight or taking weight loss medications.
When was your last dose of?
What dose were you prescribed most recently?
If you want to continue, what dose would you like to continue with?
Have you experienced any side effects?
Please give us the type of effect, duration, severity and whether they have resolved.
Do you currently take any other medication or have any allergies?
This includes prescribed medication, over-the-counter medication, and supplements. Select all that apply to you. It’s important we know about any medication so that we can make there are no complications.
Would you like your GP to be informed of this consultation?
To ensure we provide the best and safest service for you, we strongly encourage you to share your GP details so we can inform them about your treatment.

Weight Loss Treatment

Mounjaro

These fees include doctor’s consultation, prescription and delivery, No needles. Tick the dosage you would like to purchase.

Mounjaro

Wegovy

These fees include doctor’s consultation, prescription and delivery, No needles. Tick the dosage you would like to purchase.