Start Your Weight Loss Consultation

Start Your Weight Loss Consultation

Real support. No payment until you've had a one-to-one consultation.
Complete this short form to help us understand your health, medical history, and whether treatment is suitable for you.

At the end of the form, you'll be able to choose a consultation date and time that works for you. You can book a face-to-face consultation at our weight loss clinic in Whittington Pharmacy, Lichfield (WS14 9JU), or attend via video call.

At your consultation you'll speak with one of our pharmacists to explore safe, effective options for weight loss.

Step 1 - Your Measurements (to calculate BMI)

We'll use these details to check your eligibility and calculate your BMI.
Weight
You can enter your weight in kilograms or in stones and pounds (e.g. "98kg" or "15st 6lb"
Height
You can enter your height in centimetres or in feet and inches (e.g. "168"cm or "5ft 7in"

Step 2 - Medical Screening

To help us confirm if treatment is safe for you, please answer the questions below honestly.
1. Have you ever had an allergic reaction or side effect to any of the following? (tick all that apply or select 'None of the above')*

Mounjaro (Tirzepatide)Wegovy (Semaglutide)Saxenda (Liraglutide)Orlistat / Xenical / AlliInjections in generalNone of the above

Step 3 - Pregnancy, Medication & Other Factors

These questions help us understand any other factors that may affect which treatment is right for you.
1. Are you currently pregnant or planning a pregnancy in the near future?*

YesNo
2. Are you currently breastfeeding?*

YesNo

3. Are you currently taking any prescribed or over-the-counter medication, including herbal or weight loss products?*

Yes - please list them belowNo
Provide details
4. Has your weight gain been caused by a medical condition (e.g. hormonal or endocrine disorder) or medication?*

YesNo
Provide details
4. Are you comfortable with self-injecting if required (e.g. for Mounjaro, Wegovy or Saxenda)? Don't worry - we' offer full training in-person or via video to ensure you're completely confident.*

YesNoNot sure - I'd like support
5. Do you have any questions or concerns you'd like to raise with the pharmacist before your consultation?

YesNo
Provide details

Step 4 - Treatment Interest & Booking

You're nearly done! Just tell us which treatment you're interested in, choose a time that works for your consultation.
1. Which treatment would you like to start with? - Please note: We can also support you if you've already been prescribed one of these treatments elsewhere.*
2. Have you used any weight loss treatments before?

Yes - I've used one or more of these before (please specify below)No - this would be my first timeI've used something else (please specify below)
Please provide details
3. How would you like to have your consultation?

I'd like a video consultation with a pharmacistI'll visit Whittington Pharmacy in person (13b Main Street, Lichfield, WS14 9JU)I'm not sure yet - I'll decide later
4. Book your one-to-one consultation
Select a time that works for your one-to-one consultation. You'll receive confirmation by email or phone.

Step 5 - About You

To confirm your consultation and contact you with next steps, please complete your details below. These won't be shared are are kept fully confidential.
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender at Birth*
Phone Number*
Please enter a valid phone number.
Email Address*

Confirmation Emailexample@example.com
Home Address (optional)

Street Address

Street Address Line 2

City

Post Code

Step 6 - Final Confirmation

Before you submit your form, please read and confirm the statements below.
Please tick to confirm:*

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that this will be reviewed by a pharmacist before any treatment is offered.I understand that my personal data will be processed sercurely and only used to assess my suitability for weight loss treatment, in ine with your privacy policy.
Should be Empty:

Step 1 - Your Measurements (to calculate BMI)