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 current weight and height?*
That makes our current BMI...

Are you currently taking weight loss medication?*

YesNo

What medication are you interested in taking?

Mounjaro 2.5mgWegovy 0.25mg

What weight loss medication and dose are you currently taking? Please note we do not prescribe Ozempic, choose your answers using the Wegovy dosage.

Name*

First NameLast Name
DOB*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityCounty

Zip CodeCountry
Email*
example@example.com
Phone Number*

Area CodePhone Number
Now, lets confirm that its you
Please upload a full length photo of yourself, make sure you are not wearing baggy clothes and that it is a true and very recent image. *

Cancelof
Now, if you could upload an image or scan of your photo ID (eg. driving licence or passport)*

Cancelof
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
Do you agree with the above?*

Agree

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

AMBER CATEGORY. Reason:
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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Let's start with some basic questions

Now for some important health questions

Tell us a bit about your goals

Now, lets confirm that its you

Thank you for that, just one last thing