Weight Loss Consultation

Step 1 of 4

About You

First Name*

Last Name*

Date of Birth *

Email *

Phone *

Weight Assessment

Height: *

Weight: *

Step 2 of 4

Your Health

Do you suffer from diabetes, heart disease, high blood pressure or high cholesterol? * Yes No

Are you allergic to Orlistat, Wegovy or Mounjaro? * Yes No

We are unable to supply you with medication for weight loss. Please consult your GP or doctor.

Are you pregnant or breastfeeding or intending to become pregnant or start breastfeeding whilst taking medication? * Yes No

We are unable to supply you with medication for weight loss. Please consult your GP or doctor.

Have you been diagnosed with any of the following? * Yes No

Problems absorbing food (chronic malabsorption syndrome) diagnosed by a GP
Liver problems
Kidney problems
Thyroid problems
Surgery to remove your gallbladder (cholecystectomy)
Cholestasis (condition where the flow of bile from the liver is blocked)
Any serious medical condition which may require immediate hospitalisation

We are unable to supply you with medication for weight loss. Please consult your GP or doctor.

Have you ever suffered from an eating disorder such as Anorexia Nervosa or Bulimia? * Yes No

We are unable to supply you with medication for weight loss. Please consult your GP or doctor.

Please upload a FULL body image of yourself which also shows your face. *

PLEASE NOTE - ANY MISSED PICTURES WILL DELAY YOUR ORDER. All pictures are sent secure, confidential and are only seen by the clinical team. If for any religious or any other reason you do not want to show your face, please let us know and we can arrange a video call instead.

Step 3 of 4

Your Medication

Are you currently taking any over-the-counter or prescription medication or any recreational drugs? * Yes No

Are you taking any of the following medications? * Yes No

Other weight loss treatments
HIV medication
Fat-soluble vitamins
Oral anticoagulant drugs used to thin the blood such as Warfarin
Ciclosporin (used after organ transplants, for severe rheumatoid arthritis and some severe skin conditions)
Thyroid Medicine (levothyroxine)
Iodine salts
Amiodarone (used for heart rhythm problems)
Acarbose (an anti-diabetic drug used to treat type 2 diabetes mellitus)
Anticonvulsant/anti-epileptic drugs
Antidepressants
Antipsychotics including lithium
Benzodiazepines including diazepam

We are unable to supply you with medication for weight loss. Please consult your GP or doctor.

Are you taking any medicine for high cholesterol, diabetes or high blood pressure? * Yes No

You must speak to your GP or doctor to discuss the dosage of your medicine when your weight changes.

Are you using an oral contraceptive? * Yes No

You must speak to your GP or doctor to discuss the dosage of your medicine when your weight changes.

Step 4 of 4