Weight Loss Injection Eligibility Form
Please complete this form to help our clinicians determine if weight loss medication is a safe and appropriate option for you
Full Name
*
First Name
Last Name
Delivery Address
*
Street Address
Street Address Line 2
City
Country
Postcode
Phone Number
-
Area Code
Phone Number
Date of Birth
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Weight
Please specify kg, stones or lbs
Height
Please specify ft or cm
Medical History:
*
Have you previously used any weight loss treatment?
Yes
No
Please specify weight loss treatment
When did you use this treatment
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Signature
Check eligibility
Check eligibility
Should be Empty: