Weight loss Form

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By completing this submission form you are consenting for this information to be shared with our PGD partner.* This field is required.Third party PGD provider pharmadoc
YESNO
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Name* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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Brazil
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Mali
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Mayotte
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Northern Mariana
Norway
Oman
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Palau
Palestine
Panama
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Paraguay
Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
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Romania
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Rwanda
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eSwatini
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Tanzania
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Vanuatu
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Vietnam
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Isle of Man
US Virgin Islands
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Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Phone Number* This field is required.
Phone Number
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Email* This field is required.
example@example.com
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Please answer the questions as accurately as possible, and if you're unsure of anything please contact us or ask your doctor. Your treatment outcome will ultimately be a joint decision between you and our prescribing clinician. Before you continue, please check the following important information: * This field is required.Weight loss medications are not a replacement for a healthy lifestyle, and should be used alongside a calorie-controlled diet and increased physical activity. Only one type of weight loss medication can be used at the same time. If your body mass index is over 40, other treatments like bariatric surgery may be more beneficial. To consider your other options you should speak to your doctor. We will need you to upload some photos to check your identity and current weight. We will also need to let your GP know that you are using this service.
I UnderstandNo, I need more information
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What is your sex at birth?* This field is required.This refers to your sex when you were born. We ask this because a range of health issues are specific to people based on their sex at birth.
Male
Female
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Please enter your date of birth* This field is required.
Date
Day
Month
Year
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Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?* This field is required.If these circumstances change please inform us at your earliest convenience.
Yes
No
Not applicable
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Do any of the following racial or ethnic groups make up at least half of your genetic heritage?(Select all that apply.)* This field is required.We ask this question because ethnicity impacts some of the risks calculated in this assessment. The options included are based on the government’s and the Office of National Statistics' (ONS) agreed list of ethnic groups, adapted to ensure that we have enough information to calculate your bespoke risks and recommendations.
Bangladeshi
Black -African
Black - Caribbean
Black - other
Chinese
Indian
Pakistani
White
White and Asian
White and Black African
White and Black Caribbean
White British
White Irish
Unspecified
Other
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How much do you weigh? * This field is required.Kg
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How Tall are you?* This field is required.CM
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Can you please provide us with a waist circumference
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In the last month, have you been on any weight loss medications?* This field is required.
YESNO
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Have you used any medications to help you lose weight before?* This field is required.
YESNO
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If you have previously been prescribed weight loss medication. Please upload any evidence you may have.This could be email confirmation, picture of medication etc.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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If weight loss medications have been used previously please indicate to our clinician if you want to increase/maintain strength.Note: final decision rests with clinician
Step up treatment (increase strength)
Maintain Strength (maintenance)
Clinician decision
Not Applicable
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We'd like to know some more information about your current lifestyle. Please select any of the following that apply to you.* This field is required.
I consider myself a active person. (This includes 150minutes of moderate exercise) ; or 75 minutes of vigorous exercise.
I follow a balance diet
I smoke or drink on a regular basis
I have a sedentary lifestyle
I eat processed or takeaway foods often during the week
none of the above
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It is important to maintain a healthy lifestyle while using weight loss medications. Weight loss medications are not intended to replace a balanced diet and regular exercise.* This field is required.
YES, I understandNO
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Do you have any of the following health conditions?* This field is required.select all that apply
Pre-diabetes, or diabetes
High Blood Pressure
High Cholesterol
Obstructive sleep apnoea (OSD)
Liver or Kidney disease
Irregular or fast rate
Heart Failure
Diabetic Retinopathy
Problems with your mental health (e.g. depression, mania, bipolar disorder)
Epilepsy or seizures
None of the above
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Do you have any of the following thyroid conditions?* This field is required.
Overactive thyroid (hyperthyroidism)
Underactive thyroid (hypothyroidism)
Thyroid cancer (you or close family)
multiple endocrine neoplasia type 2/MEN 2 (you or close family)
Other thyroid disease
None of the above
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Do you currently have or have you ever had any of the following gut problems?* This field is required.
Inflammatory bowel disease (e.g. ulcerative colitis or crohn's disease)
Pancreatitis
Diabetic gastroparesis
None of the above
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Do you have problems with your gallbladder?* This field is required.
Yes, I get gallbladder inflammation or gallstones
No, because I had my gallbladder removed
No
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Are you currently or have you previously been diagnosed with an eating disorder? Please note, we do not consider overeating to be an eating disorder.* This field is required.This includes binge eating disorder, anorexia nervosa, and bulimia.
YESNO
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We understand that not everyone with an eating disorder has been diagnosed. It is important to note that:* This field is required.Appetite suppressants can trigger those with bulimia or anorexia. Binge eating may lead to results being different than expected. If you think you may have an eating disorder please speak to your doctor who can assess you further.
YES, I understandNO, I need more information
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Do you have any other medical conditions that we haven't asked about yet?
Huge
Large
Normal
Small
Ok
Ok
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Are you using any of these medications?* This field is required.
Any treatment for diabetes
Antidepressants
Digoxin
Lithium
Opioid or painkillers
Warfarin
None of the above
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Do you take any medication? This includes anything that you are prescribed or have bought over the counter, or online, such as creams/ointments, vitamins or supplements, eye drops, gels, inhalers.please list any medication you take currently
Huge
Large
Normal
Small
Ok
Ok
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Do you have any allergies?Please note that this includes any dietary allergies e.g. lactose or gluten. Please list below
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Do you have any allergies?* This field is required.Please note that this includes any dietary allergies e.g. lactose or gluten.
YESNO
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Theprivatepharmacyclinic requires your informed consent before we are able to complete your treatment request. Please read the following statements carefully. I agree to read the patient leaflet before taking any medication prescribed to me. I fully understand the questions in this questionnaire and have answered honestly and truthfully. I fully understand the side effects of the treatment options, their effectiveness and alternative options, and am happy to continue with this request. I confirm and agree that any treatment prescribed to me is for personal use only. I understand that decisions about treatment are for both the prescriber and the patient to jointly consider during the consultation process, but the final decision is that of the prescriber. By clicking 'Continue' you signify that you have read, understand and agree to abide by our terms and conditions and privacy policy.* This field is required.
YES, I understandNO, I would like more information
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Please upload a photo of your ID. * This field is required.Taking a good-quality photo, Make sure we can clearly see your face (no sunglasses or hats) Choose a well-lit space, ideally with a clear background Your photo ID should be in focus and easy to see
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Select files to upload
Max. file size: 10.6MB
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The last image we need is one of your full, front-facing profile, from head to toe. Why do we need this photo? Our priority is patient safety. As injectable weight loss treatments are only suitable for people with a BMI over 27, our clinicians will review this photo to confirm before prescribing.* This field is required.You can be fully clothed, we just ask that you wear clothes that make your body shape visible, such as leggings and a fitted vest or t-shirt. Taking a good-quality photo. Make sure you’re standing so we can see your whole body If there isn’t someone around to take the photo for you, you can use a full-length mirror to capture the image All information you submit is securely stored as part of your clinical record and will only be accessed by your clinician
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Do you have preference of weight loss treatment?If unsure leave blank, our clinicians will decide most suitable product for you.
Mounjaro
Wegovy
Saxenda
Clinician decision
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Do you require a sharps bin?Cost £4.99
YESNO
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Is there anything else you would like to mention please type below.
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Do you have a referral code?If yes enter code below
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How did you hear about us?
Google search
Social media
Refferal
Other
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