Switching Provider Questionnaire

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?*

Asian or Asian BritishBlack, Black British, Caribbean, or AfricanWhiteMixedArabPrefer not to say

Have you been diagnosed with diabetes?
Have you been diagnosed with diabetes?*

I have diabetes and take medication for itI have diabetes and it's diet controlledI don't have diabetes

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.
Other Medical Conditions*

Do any of the following statements apply to you?
Mental Health*

I have been diagnosed with a mental health condition such as depression or anxietyI have or have had an eating disorder such as bulimia, anorexia nervosa, or a binge eating disorderNone of these statements apply to me
If any statements apply to you, please tell us your specific diagnosis, when you were diagnosed, and how you manage the condition.*

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*

I'm on Levothyroxine or WarfarinOther/ I take more than one prescription medication(if so, please list all medication that you currently take)I don't take any medication
Please list all prescription medication that you currently take.*

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'
Allergies*

How did you hear about us?

Facebook/InstagramTikTokGoogle or Web SearchDirect Mail or LeafletFriend or Family ReferralOther
Type in your friend or family referral name here:
If other, please describe:

Based on your responses, we are unable to approve your application automatically.

Please click the link below for your options to contact our support team.

Get in touch for assistance.
Should be Empty:

How would you describe your ethnic background?