Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 11What is your date of birth? NextWhat is your ethnicity?Asian / Asian BritishBlack / Black British / Caribbean or AfricanMixed / Multiple Ethnic GroupsOther Ethnic Group (Please Specify)White not elllegy/ellergies allergies PreviousNextWhat is your gender? MaleFemalePreviousNextUnit SystemImperialMetricHeight Height WeightWeightHeightWeight BMI --- Underweight Potential weight loss * __ kg New target weight: __ kg PreviousNextHave you ever been diagnosed with diabetes?YesNoMultiple ChoiceType 1Type 2PreviousNextHave you been diagnosed with any of the following? Eating disorder or history of disordered eating Gastrointestinal disorders Pancreatitis Active gallstones or cholestasis Liver health issues Kidney disease Respiratory health issues Cardiovascular disease High cholesterol (dyslipidemia) Cancer Bone/joint health issues History of surgery Mental health concerns Men's health issues Multiple ChoiceYesNoPlease confirm if you have had any of the following:Eating disorder or history of disordered eatingGastrointestinal disordersInflammatory bowel diseaseCoeliac diseaseChronic malabsorption syndromeGastro-oesophageal reflux disease (GORD) PancreatitisAcute pancreatitisCoeliac diseaseChronic pancreatitisHistory of pancreatitisActive gallstones or cholestasisActive gallstones or CholestasisLiver health issuesNon-Alcoholic Fatty Liver Disease (NAFLD)Non-Alcoholic Steatohepatitis (NASH)1/2Fatty liver diseaseKidney diseaseAcute Kidney Injury (AKI)End-Stage Renal Failure (ESRD)Respiratory health issuesCOPD/asthmaSleep apnoeaObesity hypoventilation syndrome or Pickwickian syndromeCardiovascular diseaseHypertensionVenous stasis diseaseSevere heart failureHigh cholesterol (dyslipidemia)High cholesterol (dyslipidemia)CancerCurrent or history of pancreatic cancerFamily history of pancreatic cancerMedullary thyroid cancer or family history of itMultiple EndocrineNeoplasia syndrome type 2 (MEN 2)Neuroendocrine tumors (history of)Gallbladder cancer or active gallstonesBone/joint health issuesOsteoarthritisAches and painsChronic severe back painHistory of surgeryThyroid surgeryBariatric operation (sleeve surgery, gastric band)Mental health concernsLow moodWeight related anxietyDiagnosed with mental health conditionMen health issuesErectile dysfunctionLow testosteronePreviousNextDo you have any other medical conditions that have not been listed? YesNoIt is crucial that our prescribers know your full medical history to ensure our weight loss plan is safe for you to start . Please tell us about any other medical conditions you have . PreviousNextHave you previously taken, or are taking, any of the following weight loss medication? Mounjaro Wegovy Ozempic Saxenda Alli MySimba Multiple ChoiceYesNoMultiple ChoiceMounjaroWegovyOzempicSaxendaAlliMySimbaOtherPreviousNextDo you currently take any other medication or have any allergies that you have not yet disclosed on this form?YesnoPlease select any of the following statements that apply to you:Other Priscription MedicationI have allergiesI don't take medicationsWrite which elllegy/ellergies you may have : PreviousNextPlease consent and agree to the following statements: You have completed this consultation yourself. All answers have been answered honestly and to the best of your knowledge. You have disclosed all prescription medication you currently take. You will not be taking this medication alongside any other weight loss medication. You have disclosed all medical conditions, allergies, serious illnesses and operations you have had. You will be the sole user of any medication offered to you through this service. You may be prescribed off-label treatment. You agree to us sharing your details and prescription with our pharmacy or a partner pharmacy so that they can dispense and deliver the medication. You are requesting this treatment only for yourself, will use it as prescribed and will read the Patient Information Leaflet supplied. You will let us know if anything you have told us in this consultation changes, especially if you start taking any new medication and get diagnosed with any new medical conditions. You are accepting our Terms of Sale and Privacy Policy. AGREE AND COMPLETE CONSULTATION PreviousNextYour Recommended Weight Loss Plan Based on the answers you gave on your consultation, you could lose up to 28 kg! With consistent use, you could get your weight down to 99 kg. UP TO 22% WEIGHT LOSS MOUNJARO 2.5mg(4 Weeks supply) Mounjaro is proven to curb your appetite and help you lose weight, the healthy way! Effective treatment to help you reach your weight loss goals. SAVE £102.00 £229.00 £127.00 UP TO 15% WEIGHT LOSS WEGOVY 0.25mg(4 Weeks supply) Wegovy, otherwise known as Ozempic, is proven to curb your appetite and help you lose weight, the healthy way! Effective treatment to help you reach your weight loss goals. SAVE £102.00 £229.00 £127.00 SELECT A PLAN TO CONTINUE Submit
