Eligibility Quiz

  • If you need help filling in this form

    please call 0330 122 7417

    or email wlsupport@clinicalalliance.co.uk 

     

     and we will assist you.

  • Are you currently taking any kind of weight loss medication?
  • Do you wish to continue taking this medication?
  • Which medication are you interested in?
  • Gender assigned at birth*
  • What is your Ethnicity?

  • Your current health

  • Are you Pregnant, breastfeeding or trying to conceive?*
  • Have you ever been diagnosed with or been treated for High Blood Pressure, or have a family history of high blood pressure?*
  • Are you currently being treated for high blood pressure?
  • Do you, or have you ever, suffered from any of the from any of the following?
  • Do you, or have you ever, suffered from any of the from any of the following?
  • Are you taking any of the medications below? (leave blank if no)
  • Are you taking any other medications?*
  • Have you ever had bariatric surgery?*
  • Do you have any allergies to Saxenda, Rybelsus, Wegovy, Ozempic,Trulicity or Victoza?*
  • What are your main reasons for wanting to lose weight? Select all that apply
  • How much exercise do you currently do a week?
  • How long have you struggled with your weight?
  • Have you ever suffered from any of the following?
  • What have you tried in the past to lose weight? Select all that apply
  • When considering treatment options, which of the following are important to you?
  •  - -
  •  -
  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Your NHS Doctor's Info: Would you like us to contact your doctor informing them of what medicine we have provided after your treatment plan is shipped? This is optional for most conditions, however for some chronic conditions we cannot treat you unless we have permission to inform your NHS GP*

  • Declarations

    Please read the following Declarations carefully and select to agree. 

  • Thank you for taking the time to answer the questions and add your details. 

  • Based on your answers there is no treatment suitable for you. If you think you have made an error in your responses, please click 'back' to review your answers

    Warning: Giving inaccurate information in a clinical consultation, could put your health at risk.

  • Should be Empty: