Weight loss Form Reorder

1
Name* This field is required.
First Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone Number
Phone Number
4
Email* This field is required.
example@example.com
5
Please enter your date of birth* This field is required.
Date
Day
Month
Year
6
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.
I UnderstandNo, I need more information
7
It isn't safe to buy weight loss treatments from more than one provider at a time, and doing so may put your health at risk.* This field is required.
I understand
8
Is there anything else you want to add? This can be anything you want our prescribers to know before prescribing you your medication such as are you currently taking any medications, please list them out.This could be new medication, any side effects experienced previously, any new medical conditions, any concerns etc.
Huge
Large
Normal
Small
Ok
Ok
9
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
10
How much do you weigh currently?* This field is required.Kg
11
Could you provide us with a waist circumference In inches
12
Do you think the medication is working Are you loosing weight/portion control
YESNO
13
Are you finding suppression is lasting one week to the next?E.g. food noise/hunger cravings are they being suppressed from one week to the next
No suppression
Partly suppressed (effects wear off towards the end)
Mild suppression
14
Since starting Mounjaro have you been initiated on any new medication Please list below
Huge
Large
Normal
Small
Ok
Ok
15
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
16
Please indicate to our clinicians if you would like to increase or maintain Mounjaro strengthOur clinicians will determine suitability of increase or maintenance.
2.5mg
5mg
7.5mg
10mg
12.5mg
15mg
Clinician decision
17
Please indicate to our clinicians if you would like to increase or maintain Wegovy strength
Wegovy 0.25mg
Wegovy 0.5mg
Wegovy 1mg
Wegovy 1.7mg
Wegovy 2.4mg
clinical decision
18
Do you require a sharps bin?Cost £4.99
YESNO
19
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
20
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