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.
I am over 18 years old and live in the UK*

Yes
I confirm all answers are provided by me and are completely truthful*

Yes
I will be the sole user of any medication offered to me through this service*

Yes

Are you currently taking any kind of weight loss medication?

YesNo
What is the name of the weight loss medication you are taking?
What dosage are you taking on your current prescription?
How long have you been taking weight loss medication
Do you wish to continue taking this medication?

YesNo
Can you let us know why you do not wish to continue with your current medication?
What is your reason for transferring your care? Please select all that apply.
Reason:
What weight changes have you had since you started weight loss medication/injections?
What was your BMI when you began taking weight loss medication?

Have you ever had bariatric surgery?*

Yes I have had bariatric surgery in the pastNo
What surgery did you have?
When did you have bariatric surgery?
Do you have any allergies to Saxenda, Rybelsus, Wegovy, Ozempic,Trulicity or Victoza?*

YesNo

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.
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Your current health