Start Your Weight Loss Treatment ConsultationPlease complete this confidential form. Our clinician will review and respond shortly. Name * First Name Last Name Date Of Birth * MM DD YYYY Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Are you registered with a GP? * Yes No Due to regulations, we need to inform your GP about this treatment. By providing these details, you consent to us sharing relevant information with your GP and accessing your NHS summary care record when necessary to ensure your safety. * GP Surgery Name Height (feet, cm or inches) * Weight kg or stones/lbs * Please calculate your BMI at NHS BMI calculator and enter below * https://www.nhs.uk/health-assessment-tools/calculate-your-body-mass-index/calculate-bmi-for-adults Are you aged 18 or over? * Yes No Is your BMI over 30 (or over 27 with a medical condition)? * Yes No How long have you been concerned about your weight? * What prompted you to seek treatment now? * What have you tried already? (Tick all that apply) * Dietary changes Exercise NHS weight‑loss programmes Slimming groups Weight‑loss medicines Other None Current diet & activity patterns * Weight or wellness goals * Have you been diagnosed with any of the following? * Type 1 or Type 2 Diabetes High Blood Pressure PCOS Sleep Apnoea High cholesterol Heart Disease or stroke Arthritis Thyroid Disorder Eating Disorder history Mental health diagnosis Gallbladder, liver or kidney disease None Do you currently experience any of the following? (Tick all that apply) * Unexplained weight loss Blood in stool or vomit Persistent vomiting/diarrhoea Difficulty swallowing Chest pain or breathlessness on minimal activity Syncope or fainting Severe abdominal pain Night sweats or fever with weight loss Family history of bowel/stomach/pancreatic cancer Bariatric surgery history None If any are ticked, please elaborate Are you actively trying to lose weight through diet and lifestyle changes? * Yes No Have you previously used any prescription weight loss medication? * No - I will be starting them for the first time Yes- I have used weight loss injections in the past 4 weeks Yes- I have used weight loss injections in the past 4-8 weeks Yes- I last used weight loss injections more than 8 weeks ago If yes, please describe your experience (side effects, success, etc.) * Treatment Preferences * What treatments would you consider? (Tick all that apply) Semaglutide (Wegovy/Ozempic) – weekly injection Tirzepatide (Mounjaro) – weekly injection Liraglutide (Saxenda) – daily injection Orlistat (Xenical/Alli) – meal‑time tablet Unsure – please advise Are you pregnant, planning to become pregnant, or breastfeeding? * Yes No Do you have a personal or family history of thyroid cancer or MEN2 syndrome? * Yes No Do you have pancreatitis or a history of it? * Yes No Do you have gallstones or gallbladder issues? * Yes No Do you suffer from depression or eating disorders (e.g., anorexia, bulimia)? * Yes No Do you have liver or kidney disease? * Yes No Are you allergic to any of the following: Semaglutide, Tirzepatide, Orlistat? * Yes No If yes, please describe your reaction Please list all current medications and supplements you are taking * Are you taking insulin or sulfonylureas for diabetes? * Yes No Are you taking ciclosporin or blood thinners (e.g., warfarin)? * Yes No Which treatment would you prefer to explore? * I prefer weekly injectable pens that will control my appetite to help me lose up to 20% body weight I prefer tablets that prevent the absorption of fat from food to help me lose up to 5% body weight I’m not sure Would you like lifestyle advice and support alongside treatment? * Yes No Consent & Declaration * I confirm that the information I have provided is true and accurate. I understand that this is a private medical weight loss service and not part of NHS care. I consent to data processing for medical purposes, in line with GDPR. I understand the risks, benefits, and limitations of weight loss treatment. You understand that Wegovy and Mounjaro are weekly injections administered under the skin (upper arms, stomach, or upper legs). We provide an easy step-by-step video showing you how to do this at home. You understand that if this is your first time using Mounjaro or Wegovy, you must start with a one-month supply of the lowest dose. For the best and safest results, the dose should be gradually increased each month, provided you are tolerating the medication well. Each time you reorder your medication, you agree to provide an accurate and up-to-date weight reading so that we can safely monitor your progress. If you have been using Mounjaro or Wegovy for at least one month, you may select a 2-month supply of your current dose— provided you have not experienced any new or concerning side effects, have not lost more than 10% of your body weight in the past month, and your BMI remains above 20. You understand that if you experience concerning side effects, you can contact us, your GP, or another healthcare professional. You agree to read about potential side effects in the Patient Information Leaflet. You agree to stop treatment and seek urgent medical attention if you experience severe dehydration or symptoms like dark urine, blood in stool/vomit, confusion, or vomiting/diarrhoea lasting over 72 hours. You understand that Mounjaro and Wegovy may reduce the effectiveness of oral contraceptives. Use additional non-oral contraception (e.g., condoms) during treatment. Stop Mounjaro at least 4 weeks before trying to conceive and Wegovy at least 8 weeks. If pregnant during treatment, stop and consult your GP. You confirm you are not currently pregnant. You understand that there may be an increased risk of pancreatitis, gallbladder issues, and gallstones. If you experience abdominal pain, seek medical advice. You understand that if you develop a lump in your neck, a hoarse voice, or other unusual symptoms, stop the medication and consult your doctor. You understand that injectable weight loss treatments may cause mood changes. If you experience depression or thoughts of self-harm, stop the treatment and contact your doctor. You understand that injectable weight loss medications should not be combined with other weight loss medications. You understand that for best results, a healthy, reduced-calorie diet and regular physical activity are important. Aim for at least 150 minutes of moderate-intensity exercise each week. You will read the patient information leaflet supplied with your medication. If you have allergies or contraindications, you will not take the medication and will contact us for advice. You have disclosed any allergies and medical conditions by completing the general health questions. You agree that if needed a clinician may contact you via email, whatsapp or telephone to offer advice, suggest treatments, or gather more information for an accurate diagnosis. You consent to us informing your GP of any weight loss injection treatments prescribed. Thank you. Your form has been received. A prescriber will review your details and contact you within 24–48 hours. ⚠️ If you are pregnant, breastfeeding, or have a history of thyroid cancer, GLP-1 injections may not be suitable for you. We will carefully review your form and advise on safe and appropriate treatment options.
