Medical Weight Loss Consent Form

1

Photos

2

Full Name* This field is required.

First Name

Last Name

3

Email Address* This field is required.

example@example.com

4

Phone Number* This field is required.

Please enter a valid phone number.

5

Date of Birth* This field is required.

Date

6

Assigned Sex at Birth* This field is required.

Male

Female

Other

7

Are you between the ages of 18 and 74?* This field is required.

Yes

No

8

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

9

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

10

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

Yes

No

11

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

Yes

No

12

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

13

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

Yes

No

14

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

Yes

No

15

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

Yes

No

16

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

Yes

No

17

Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome?* This field is required.

Yes

No

18

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?* This field is required.

Yes

No

19

Are you taking steroids or medication to treat your thyroid?* This field is required.

Yes

No

20

Have you taken injectable weight loss medication in the last 4 weeks?* This field is required.

Yes

No

21

Do you understand that you will be asked to provide evidence of a prescription with an alternative provider if the following applies to you:* This field is required.

Yes

No

22

Do you understand that GLP-1 injectable weight-loss medication (such as Mounjaro and Wegovy) may reduce the effectiveness of oral contraceptives and that you must use additional non-oral contraception methods (e.g. condoms) during your treatment?* This field is required.

Yes

No

23

Do you understand that this medication should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child?* This field is required.

Yes

No

24

Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice?* This field is required.

Yes

No

25

Do you understand that injectable weight loss medications should not be used with other weight loss medications?* This field is required.

Yes

No

26

Do you understand if you develop any lumps in the neck or hoarse voice whilst taking this medication, you should stop the medication and speak to your doctor?* This field is required.

Yes

No

27

Both weight loss and injectable weight loss treatment has been associated with a lowering of mood. If you are experiencing this (depression, thoughts of self harm or other mental health issues), do you understand you should stop treatment and speak to your doctor?* This field is required.

Yes

No

28

Appointment