Weight Loss Application

  • If you need help filling in this form

    please call us on 0330 122 7417

    or email wlsupport@clinicalalliance.co.uk 

     

  • Let's start with some basic questions

  • What is your Ethnicity?*
  • What was your assigned gender at birth?*
  • Are you Pregnant, breastfeeding or trying to conceive?*
  • Are you currently taking weight loss medication?*
  • What medication are you interested in taking?
  • You have told us that you are on Wegovy 2.4 mg, your options would be to stay at this dose, drop down a dose to 1.7 mg, or move to Mounjaro, (Please select your preference. If you need to speak with someone about this please head to the website to get in touch)
  • You have told us that you are on Saxenda, we do not prescribe this. You can stay with your existing provider or swap to one of the following 2 medications. You must agree to refrain from taking Saxenda before we can prescribe
  • You have told us that you are on Wegovy 1 mg, your next dose would be Wegovy 1.7 mg . You have the option to stay with Wegovy or move to Mounjaro, Please select your preference
  • You have told us that you are on Wegovy 1.7 mg, your next dose would be Wegovy 2.4 mg . You have the option to stay with Wegovy or move to Mounjaro, Please select your preference
  • You have told us that you are on Wegovy 0.5 mg, your next dose would be Wegovy 1 mg . You have the option to stay with Wegovy or move to Mounjaro, Please select your preference
  • You have told us that you are on Wegovy 0.25 mg, your next dose would be Wegovy .5 mg. You have the option to stay with Wegovy or move to Mounjaro, Please select your preference
  • You have told us that you are on Mounjaro 15 mg, your next dose options would be to stay at this dose or to step down to Mounjaro 12.5 mg (if you would like to discuss your options please head to our website to speak to a member of the team)
  • You have told us that you are on Mounjaro 7.5mg, Please carefully select the medication and dose you would like us to consider prescribing. Please get in touch if you need help
  • You have told us that you are on Mounjaro 10 mg, your next dose options would be to stay at this dose, move to Mounjaro 12.5 mg or go down to Mounjaro 7.5mg (if you would like to discuss your options please head to our website to speak to a member of the team
  • You have told us you are on Mounjaro 5mg, Please carefully select the medication and dose you would like us to consider prescribing. If you are changing brand you will need to select the smallest dose of the new drug, so the next options available to you are shown.
  • You have told us that you are on Mounjaro 12.5 mg, your next dose options would be to stay at this dose, move to Mounjaro 15mg or to step down to Mounjaro 10 mg (if you would like to discuss your options please head to our website to speak to a member of the team)
  • You have told us that you are on Mounjaro 2.5 mg, Please carefully select the medication and dose you would like us to consider prescribing. If you are changing brand you will need to select the smallest dose of the new drug, so the next options available to you are shown.
  • If you have selected to move to an alternative medication can you let us know why?*
  • Have you ever had bariatric surgery?*
  • Why are you looking for weight loss meds following bariatric surgery?*
  • Do you have any known allergies to the ingredients found in Wegovy or Monjaro medication? ( full list can be found on our website)*
  • Have you ever suffered from any of the following?*

  • Now for some important health questions

    Please read them carefully
  • 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, have you ever had or are you undergoing investigations for, 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?*

  • Tell us a bit about your goals

  • 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?
  • 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?
  • DOB*
     - -
  •  -

  • Now, lets confirm that its you

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  • Thank you for that, just one last thing

    We need to ensure the service and medication are used properly and that you understand the commitment this takes.

  • Declarations

    Please read the following Declarations carefully and select to agree. 

  • In submitting this form I agree with the following statements:

    • I am over 18 years of age and live in the UK
    • All my answers are completely truthful
    • I will be the sole user of any medication offered to me
    • I will read the enclosed leaflet thoroughly
    • I will stop taking any other weight loss medication immediately and recognise taking 2 weight loss medications simultaneously could be seriously detrimental to my health.
    • I will speak with a local clinical providers, such as my GP or hospital, or 111 if I experience any of the serious symptoms listed, then update CSSA
    • I understand your doctors take the answers I have provided in good faith and base their prescribing decisions accordingly
    • I know incorrect information can be hazardous to my health
    • I will advise my GP of my use of this medication if advised to do so
    • I have the capacity to make my own decisions about my health
    • Should I stop using the medication, I will dispose of the remainder in line with enclosed guidance

  • Thank you

     

    Based on your answers today, I'm afraid we do not have a pathway that we can offer you.

    If you feel you have made an error in your form please return and resubmit your answers.

    You can also book in with your GP who may be able to offer additional support via the NHS

  • The answers you have given suggest you are eligible for our Weight Loss medication!

    The following link will take you to the medication page, you can checkout and pay for your prescription

     

     ORDER & PAY FOR PRESCRIPTION HERE

     

    Once our Clinicians recieve your order, they will double check everything and will send your medication, you will recieve update emails throughout 

     


     

     

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