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Do you agree and consent to the following?
You are completing this consultation for yourself and to the best of your knowledge.
You will disclose any medical conditions, serious illnesses or operations you have had
You will disclose any prescription medication you currently take, and only use one treatment at a time
You accept our Terms & Conditions and Terms of Sale.
Understand that your health records contain confidential patient information, which may be used to help with research, planning, and marketing.
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What is your gender?
Male
Female
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Date of Birth:
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Are you trying to get pregnant or currently pregnant or currently breastfeeding?
Yes
No
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Height (in cm):
Weight (in kg):
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What is your ethnic background?
Asian or Asian British
Black (Caribbean, African)
Mixed ethnicities
Other ethnic group
White
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Do you currently have or have ever been diagnosed with an eating disorder?
Yes
No
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Do you have medication controlled diabetics?
Yes
No
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Do you take any other medications?
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Do you have any of the following conditions? (Tick all that apply)
Prediabetics
Raised Cholesterol
Osteoarthritis (OA)
Polycystic Ovarian Syndrome (PCOS)
Hypertension (Raised Blood Pressure)
Obstructive Sleep Apnoea (OSA)
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Do you have a history of gallstones or pancreatitis?
Yes
No
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Do you have or have you ever been diagnosed with thyroid medullary cancer or Multiple Endocrine Neoplasia?
Yes
No
Please specify the medication:
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Do you have any allergies to any medications?
Yes
Please specify the medication:
No
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Congratulations!!!! You are eligible for FREE GP Video Consultation
Please enter your details below so that our GP will contact you to discuss with your weight loss treatment
Congratulations, you are eligible for Weight Loss treatment. Please fill in the following details:
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