Medical Weight Loss Consent Form

1

Full Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Email Address* This field is required.

example@example.com

4

Date of birth* This field is required.

Date

5

Assigned Sex at Birth* This field is required.

Male

Female

Other

6

What is your current weight (kg)?* This field is required.

7

What is your current height (cm)?* This field is required.

8

Do you suffer from prediabetes, heart disease, high blood pressure, high cholesterol or obstructive sleep apnoea?* This field is required.

Yes

No

9

Do you suffer from diabetes?* This field is required.

Yes

No

10

If you have type 2 diabetes, are you on any injections or tablets to control your blood sugar, other than metformin?* This field is required.

Yes

No

11

Have you experienced an allergic reaction to Wegovy, Mounjaro, Semaglutide, Saxenda or Liraglutide before?* This field is required.

Yes

No

12

Have you ever suffered with an eating disorder?* This field is required.

Yes

No

13

Are you pregnant, breastfeeding, or trying to conceive?* This field is required.

Yes

No

14

Have you been diagnosed with or had surgery for any of the following?* This field is required.

Yes

No

15

I have read and understood the information provided in this Medical Weight Loss Consent Form. I voluntarily consent to participate in the weight loss program.

16

Appointment