What are your weight loss goals?

Have you tried to lose weight before?
Select OptionYesNo

What has been your experience with previous weight loss attempts?

Are you currently experiencing any symptoms that may be related to your weight?
Select OptionYesNo

Have you been diagnosed with any conditions that could affect your weight?
Select OptionYesNo

Have you had any tests to evaluate your condition?
Select OptionYesNo

Have you been prescribed medication for weight loss before?
Select OptionYesNo

Are you currently taking any medication for weight loss?
Select OptionYesNo

Have you experienced any side effects from weight loss medications?
Select OptionYesNo

Have you tried any non-medication treatments for weight loss?
Select OptionYesNo

Have you used over-the-counter treatments for weight loss?
Select OptionYesNo

- I agree to consult with my healthcare provider before starting any new medication.
- I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Select OptionYesNo

- I consent to my personal and medical information being used to assess my suitability for the prescribed medication.
- I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Select OptionYesNo

- I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.
- I understand that providing false information may result in my order being declined and may have health implications.

Select OptionYesNo

Due to new regulations, we are required to have a 5-minute video call to verify your weight before we can supply weight loss treatment.
Once you place your order, we will email you to book a call with our specialist via FaceTime, WhatsApp Video, Google Meet, Microsoft Teams, or Zoom.
Please confirm that you understand and are happy to proceed with this requirement.

Select OptionYesNo

Consent to access Summary Care Record (SCR) if required to view patient’s GP record.
Select OptionYesNo