Weight Assessment Form - New Customer

  • Acknowledgement and consent

    Please read about weight loss medication, acknowledge understanding and consent.
  • Do you agree to the following? (Select ALL to continue)*
  • How old are you?

  • Calculate your BMI

  • Do you have any of the following conditions?*
  • Do you have gall bladder or bile duct issues?*
  • Do you have diabetes?*
  • Are you pregnant, breastfeeding or trying to conceive (now or in the near future)?*
  • Are you currently using oral hormonal contraception?*
  • Do you have any eating disorder or made yourself sick or vomit to loose weight?*
  • Have you ever had serious head injury or trauma*
  • Do you have problems with your pancreas? This include history or current pancreatitis*
  • Do you have or been told you have chronic malabsorption synfrome?*
  • Do you take any medication (from your GP, over-the-counter or herbal medication)?*
  • Has your dose changed forthe following medications in the past 3 months - Thyroxine, Antidepressants or oral steroids*
  • Do you have any allergies?*
  • Have you ever been diagnosed with an eating disorder (such as anorexia, binge eating disorder or bulimia) by a healthcare professional?*
  • Are you CURRENTLY using or have used any of the following weight loss medication in the past 4 weeks?*
  • Have you EVER used any of the following weight loss treatment?*
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  • Are you CURRENTLY taking any of the following medications - Aniodarone, Carbamazepine, Ciclosporin, Clozapine, Digoxin, Fenfluramine, Glibenclamide, Gliclazide, Glimepride, Glipizide, Insulin, Oral Methotrexate, Phenobarbital, Phenytoin, Somatrogon, Tacrolimus, Theophyline, Tolbutamide, Warfarin.*
  • Do you have any of the following condition?*
  • Eligibility Status

  • About You

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  • Type a question
  • Select product you are interested in.*

  • I understand I should use one weight loss product at a time

    I understand that I will stop treatment and inform Tabi Health and/or seek medical attention if I experience severe dehydration, e.g. dark urine, confusion, blood in stool or vomit, diarrhoea lasting longer than 72 hours, or being unable to keep food down without vomiting/diarrhoea

    I understand that if I experience any troublesome side effects from Wegovy/Mounjaro, I can contact Tabi Health Pharmacy, my GP, or another healthcare professional for advice. I confirm that I will read about the side effects in the Patient Information Leaflet.

    The medical information I have provided is true and accurate to the best of my knowledge, and I consent to the medicine being administered.

    I agree to inform my GP of any change to my health as soon as possible, as I understand this could impact the suitability of the medication I am being prescribed.

    I understand that my personal information, including name, surname, email, telephone, date of birth (DOB) and GP details, will be securely uploaded to the Tabi Health third party dtabase for electronic storage, and it will be kept in line with data protection regulations along with the details of the consultation (i.e., medicines provided).

    I understand that I can speak to a member of staff about any queries regarding this consultation, including exercising my rights under data protection legislation.

    I will contact Tabi Health if I start taking any new meidicnes, if my medical conditions chnage, or if I experience side effects.

    I will stop treatment and contact my doctor if i develop any lumps in my neck or a hoarse vocie while taking this medication

    I understand that this medication may increase the risk of pancreatitis, gallbladder problems, and gallstones. If i experience abdominal pain, I will seek medical advise.

    I will read the patient information leaflet provided with my medication

    I understand that this medication can make the pill less effective. I should use extra prtection like condoms, during treatment.

  • Read above information before clicking below*
  • Read above information before clicking below*
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