MHP Clinic Consultation Request Form

Full Name*

First NameLast Name

Email Address*

example@example.com

Phone Number*

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Weight *

Stones and pounds or kilograms

Date of Birth*

DayMonthYear

Height *

Feet and inches or centimetres

GP Name and Address*

It is our policy to inform your GP if commencing medications. Please tick "YES" to give us permission to do so. By ticking "NO" we cannot accept you as a client.*

YesNo

Do you suffer from gastro-intestinal problems (e.g. gallstones, pancreatitis, inflammatory bowel disease)?*

NoYes (give details below)

Do you suffer from any mental health problems?*

NoYes (give details below)

Do you have any other medical problems?*

NoYes (give details below)

Do you suffer from diabetes?*

NoYes (give details below)

Do you, or any of your family, have a history of thyroid cancer?*

NoYes (give details below)

Please list any other medical issues

Please list all prescribed medications

Please describe your typical daily diet

What weight loss interventions have you previously tried?

Are you currently taking any weight loss treatments e.g. Orlistat, Wegovy, Mounjaro?*

NoYes

How did you hear about us?

Through a friendGoogle searchSocial mediaOther

Have you answered all questions truthfully and consent to Dr. Thompson reviewing your medical history?*

Yes

Initial consultations include:

A comprehensive medical assessment that covers your past medical history and current medications.
A full medical examination that includes measurements of your weight, height, blood pressure, and waist circumference. This helps us understand your unique health status and tailor our approach accordingly.
Development of an individualised medical weight loss plan specifically designed for you, incorporating dietary recommendations, exercise guidance, and behavioral strategies tailored to fit your lifestyle.
Prescribing of evidence-based medications, including options like Wegovy and Mounjaro is included in the price of the consultation when appropriate, ensuring you receive the necessary support throughout your weight loss journey.
Comprehensive weight maintenance plans designed to help you sustain your weight loss and ensure healthy lifestyle choices for the long term.
You will also receive a bonus MHP Clinic booklet that provides valuable education on topics such as:
Why is it so hard to lose weight?
How to eat well in a hurry?
How to eat out and not gain weight?
How to easily add protein to your diet?
High Protein/Low-Calorie Diet Meal Plans.
and much more...

A £100 deposit is required to reserve your appointment. If it is decided either by you or Dr Thompson not to proceed with the weight management programme the cost of the consultation will be £100 only i.e. the deposit.

Do you have any preference to the weight loss medication prescribed?*

WegovyMounjaroI don't know and I'll discuss it with Dr. Thompson during my initial consultation.

Are you hoping to qualify for any of our promotions?

1st Month Free (see website for details)No