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Quick login consent(Required)

I Understand

First Name(Required)

Middle Name

Last Name(Required)

Email(Required)

Telephone(Required)

Address(Required)

Street Address City ZIP / Postal Code

What was your assigned sex at birth?(Required)

This online consultation depends on knowing your assigned sex at birth, not your gender identity. We need to know this information so we can ask relevant clinical questions and recommend suitable treatments.

Male

Female

What is your date of birth?(Required)

DD slash MM slash YYYY

Do you confirm that:(Required)

You understand that it is in your best interests to answer all questions in full, providing accurate and honest information.

You are using this service yourself, of your own free will and any medicine is for your personal use only.

You have capacity to understand all about the condition and medication information we have provided in advance and that you give fully informed consent to the treatment option provided in your best interests.

You have read and fully understand what this medicine is used for, as well as all the possible treatment options for your condition and are aware of all the possible benefits, risks or side effects.

You agree to read the patient information leaflet before taking any medicine and use the medication only as directed.

I confirm.

People of certain ethnicities may be suitable for treatment at a lower BMI than others, if appropriate. Do any of the following apply to you?(Required)

African-Caribbean

Black African

Chinese

Middle Eastern

South Asian

Other Asian

Please provide your height.(Required)

Feet & Inches

Centimetres

Feet(Required)

Inches(Required)

Centimetres(Required)

Please provide your weight.(Required)

Stones

Kg(Required)

Stones(Required)

lb(Required)

When did you last check your weight?(Required)

DD slash MM slash YYYY

What is your target weight for the next 12 months?(Required)

Stones

I have no target weight in mind

Kg(Required)

Stones(Required)

lb(Required)

A healthy target weight is 0st NaNlb (0 kg). A healthy BMI lies between 18.5 and 24.9.

Have you previously taken any medicine to help with weight loss?(Required)

Yes

Which weight loss medicine did you use most recently?(Required)

Wegovy

Saxenda

Rybelsus

Mounjaro

Ozempic

Mysimba

Xenical/Orlistat

Others

Which Wegovy dosage did you use most recently?(Required)

0.25mg (green label pen)

0.5mg (pink label pen)

1mg (brown label pen)

1.7mg (blue label pen)

2.4mg (black label pen)

When did you use it?(Required)

For how long?(Required)

Which Rybelsus dosage did you use most recently?(Required)

3mg (green box)

7mg (red box)

14mg (blue box)

Which Mounjaro dosage did you use most recently?(Required)

2.5mg

5mg

7.5mg

10mg

12.5mg

15mg

Which Ozempic dosage did you use most recently?(Required)

0.25mg (grey label pen)

0.5mg (red label pen)

1mg (blue label pen)

When did you use it?(Required)

For how long?(Required)

When did you use it?(Required)

For how long?(Required)

Which medicine(s) did you use?(Required)

When did you use it?(Required)

For how long?(Required)

Did you experience any undesirable side effects using this weight loss medication?(Required)

Yes

Which side effect(s) did you experience?(Required)

How long did you use it for?(Required)

When was the last time you used this treatment?(Required)

I am currently using it

In the last 2 weeks

In the last 4 weeks

More than 4 weeks ago

Have the side effects you experienced now settled?(Required)

Have you had any gaps in your treatment?(Required)

Yes

Please give an explanation of the gaps.(Required)

What was your weight when you started this treatment?(Required)

Stones

Stones(Required)

lb(Required)

Kg(Required)

How many calories do you think you consume daily?(Required)

Less than 1500

1500 - 2000

2000 - 3000

3000 - 4000

More than 4000

I know the exact amount

I don't count calories

Provide the exact amount if you know it:(Required)

How do you monitor what you eat?(Required)

How many times a week do you exercise for more than 20 minutes?(Required)

Exercise is any activity that increases your heart rate, including an active job or a brisk walk.

Little or no exercise

1 to 2 times

3 to 4 times

5 to 6 times

7 times

Please Upload a Full Body Picture

We will only ask for this every 6 months.

The picture will only be visible to you and the doctor.

We realise it’s inconvenient, but it’s for your safety and to prevent health risks in those who are vulnerable.

💡 Tip: Use a full length mirror

Example of a correct and incorrect upload:

Upload Picture

Accepted file types: jpg, jpeg, png, Max. file size: 5 MB.

Remind me to upload my picture later

Yes, remind me later

I would prefer not to upload an image.

Have you been diagnosed with high blood pressure (with or without treatment)?(Required)

Yes

Which medication(s) do you take?(Required)

What is your last blood pressure reading?(Required)

Do you have any allergies?(Required)

Yes

Please provide more information.(Required)

Have you ever had any medical conditions or surgery not previously mentioned in this form, or is there any further information you would like to provide the doctor?(Required)

Yes

Please provide more information.(Required)

People with weight-related medical conditions may be suitable for treatment at a lower BMI than other patients, if appropriate. Do you have any of the following weight-related conditions?(Required)

Asthma
Chronic back pain
Fatty liver disease
Gallbladder disease
Heart disease (this includes high cholesterol, heart attack, stroke, coronary artery disease)
Osteoarthritis or gout
Polycystic Ovarian Syndrome (PCOS)
Sleep apnea

Yes

Select your Treatment(Required)

Our doctors advise you to take one of the following dosage(s).

Tirzepatide

Semaglutide

Tirzepatide Doses(Required)

Semaglutide Doses(Required)

Treatment Questions

Have you been diagnosed with Diabetes (with or without treatment)?(Required)

Yes

Which medication(s) do you take?(Required)

Do you suffer from diabetic eye disease?(Required)

Yes

⚠️ Unable to prescribe: This treatment cannot be prescribed online. Please consult your GP for further advice.

Have you been diagnosed with an underactive thyroid, for which you take Levothyroxine?(Required)

Yes

What dose of Levothyroxine do you take?(Required)

Do you take any other medicines including prescription, over-the-counter or recreational drugs?(Required)

Yes

ℹ️ IMPORTANT INFORMATION: It is recommended that if you take a medication with a narrow therapeutic index such as warfarin, digoxin, and lithium, then you will need close monitoring during treatment with this weight loss treatment.

Please provide the name and dose of all medicines you are currently taking.(Required)

Please tell us which medical conditions you are taking these medications for.(Required)

Have you had any weight loss surgery (bariatric) such as a gastric bypass or gastric band in the past?(Required)

Yes

⚠️ Unable to prescribe: This treatment cannot be prescribed online. Please consult your GP for further advice.

Do you suffer from depression?(Required)

Yes

Please provide more information.(Required)

⚠️ You may proceed: This medication can affect mood. If you experience any sudden change to your mood, behaviour or thoughts while taking this medication (e.g. depression or suicidal thoughts), you should stop treatment and seek immediate medical advice.

Have you ever had any suicidal thoughts?(Required)

Yes

Please provide more information.(Required)

Have you ever been diagnosed with any of the following conditions?(Required)

Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
An eating disorder (e.g. anorexia or bulimia)
Cardiovascular (heart) problems, especially heart failure or abnormal heart rhythm (palpitations)
Gastroparesis
A stroke
Severe kidney or liver problems
Thyroid carcinoma
Pancreatitis
Obesity caused by endocrine (gland) disorders

Yes

Do you have a family history of Medullary Thyroid Carcinoma (MTC)?(Required)

Yes

Who in your family has had this? Please provide more information.(Required)

Consent(Required)

Do you understand that this medication is given as a subcutaneous (under the skin) injection, and do you feel confident administering it yourself?

I understand

Do you drink alcohol?(Required)

Yes - 1-2 units/week

Yes - 3-5 units/week

Yes - 6 or more units/week

⚠️ IMPORTANT INFORMATION: We advise you to limit your alcohol consumption, as it is high in calories and affects your response to treatment.

Do you have any physical conditions that prevent you from exercising?(Required)

Yes

How does it impact you?

Do you consent for us to inform your GP, and if necessary, have a dialogue so that we can provide effective ongoing continuity of care?

Yes

GP Name

Gp Email

Gp Postcode or City

Please confirm the following before starting treatment:(Required)

You understand how to properly store this medication and how to dispose of needles and sharps safely.

You have previously attempted weight loss through diet, exercise, and lifestyle changes before considering prescription medication.

You understand that this treatment must be combined with a healthy diet and regular exercise.

If you notice any sudden changes in mood, behaviour, or thoughts (such as depression or suicidal thoughts), you will stop treatment immediately and seek medical help.

You are aware that this medication may cause gastrointestinal side effects (e.g., abdominal pain, nausea, vomiting, diarrhoea). These can increase the risk of dehydration. You will drink plenty of fluids, replace electrolytes, and seek medical attention if symptoms are severe.

If you are a woman of childbearing age, you will take appropriate precautions to avoid pregnancy while using this medication and for two months after stopping it, as it may harm an unborn child. If you use hormonal contraception, please note that Mounjaro may reduce its effectiveness. You should switch to a non-oral method or add a barrier method of contraception.

You will read the patient information leaflet provided with the medication before starting treatment. If you have any concerns, you will contact your doctor before beginning.

I Confirm

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Weight Management Consultation

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