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Please kindly fill in your name, email and phone number. We need to know this information so we can ask relevant clinical questions, define our communication channels and recommend suitable treatments.

First Name *

Email Address *

House Number *

City *

Last Name *

Phone Number *

Address *

Post-Code *

What was your assigned sex at birth?

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.

What was your assigned sex at birth *

Male
Female

What is your date of birth?

What is your date of birth? *

Do you confirm that:

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 the capacity to understand all about the condition and medication information we have provided in advance, and 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.

Do you confirm that:

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?

Ethnicity

Please provide your height.

Height Feet

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Please provide your weight.

Weight

When did you last check your weight?

When did you last check your weight? *

What is your target weight for the next 12 months?

Target weight for the next 12 months

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

High blood pressure

Yes
No

Do you have any allergies?

Allergies

Yes
No

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?

Any medical conditions or surgery

Yes
No

Do you have any of the following weight-related conditions?

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

Weight-related conditions

Yes
No

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Your Personal Details

What was your assigned sex at birth?

What is your date of birth?

Do you confirm that:

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?

Please provide your height.

Please provide your weight.

When did you last check your weight?

What is your target weight for the next 12 months?

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

How many calories do you think you consume daily?

Are you comfortable using an injection pen?

Please upload a full body picture of yourself.

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

Do you have any allergies?

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?

Do you have any of the following weight-related conditions?