Medical Weight Loss Consent Form

1
Photos (Optional)Full body photo taken from the front and both sides.
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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
Day
Month
Year
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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
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My Products* This field is required.
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ORDER SUMMARY
Total costGBP
Mounjaro 2.5mg

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Mounjaro 5mg

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Mounjaro 7.5mg

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Mounjaro 10mg

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Mounjaro 12.5mg

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Mounjaro 15mg

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Total cost
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Appointment
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