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  • Switching Provider Questionnaire

    Please complete all mandatory fields
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  • How would you describe your ethnic background?

    What’s considered a healthy weight can be different depending on your ethnic background. Tell us how you describe yourself so we can ensure you’re getting the right care.
  • What ethnicity are you?*
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  • What sex were you assigned at birth?*
  • Are you currently pregnant, trying to get pregnant, or breastfeeding?*
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  • What is your Date of Birth?*
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  • What is your weight & height?

  • Please enter your weight & height
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  • Have you been diagnosed with diabetes?

  • Have you been diagnosed with diabetes?*
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  • Do you suffer from any of the following?

  • Liver, kidney or heart failure*
  • Pancreatitis*
  • Multiple endocrine neoplasia type 2*
  • Cancer*
  • Type 1 diabetic retinopathy*
  • Personal or family history of medullary thyroid cancer*
  • History of gallbladder problems*
  • History of inflammatory bowel disease or gastroparesis*
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  • Please list any other medical conditions you have.

    Our clinicians need to know your full medical history to make sure treatment is safe for you to take.
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  • Do any of the following statements apply to you?

  • Mental Health*
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  • Current Provider Information

    MedExpress, Pharmacy2U, Other
  • When did you start your weight loss medication?*
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  • Which weight loss medication are you currently taking?*
  • When was the last time you administered a dose of your weight loss medication?*
     - -
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  • Have you ever taken any medications to help you lose weight?

    Ozempic, Saxenda, My Simba, Other  
  • Have you ever taken any medications to help you lose weight?*
  • Have you taken any of the following medications to help you lose weight?*
  • Are you presently taking this medication?*
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  • Have you taken Mounjaro, Ozempic, Rybelsus, Wegovy or Saxenda medication in the past 28 days?*
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  • Please indicate whether you are presently using any medication, such as prescription drugs, over-the-counter medications, or supplements, by selecting all that are applicable to you.

  • Are you currently using prescription drugs or over-the-counter medications*
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  • Do you have any known allergies? If yes, please list them clearly in the space provided below.

    If you do not have any allergies, simply state 'none'
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  • How did you hear about us?
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  • Informing General Practitioner (GP)

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  • Important information to review

  • Thanks for submitting your assessment. Our nursing team will now review it, and we’ll be in touch soon with the next steps in your application.

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