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Online Appointment Personal InformationFirst Name *Last NameEmail Address *Date Of Birth *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwePhone *Medical InformationPlease let us know why you are trying to lose weight? (Select all that apply) *Want to look and feel betterImproving mental healthImproving sleep or energy levelsTo increase activityAnything elseHave you been on a weight loss program or on any weight loss treatment in the last 6 months (injectables or oral)? *NoYes. Please clarifyWhat is your height?In centimeters (cm)In feet/inches (ft/inch)What is your current weight?In centimeters (cm)In feet/inches (ft/inch)What is your ethnicity? *CaucasianEast Asian or East Asian BritishSouth Asian or South Asian BritishBlack, African, Caribbean or Black BritishMiddle EasternI would prefer not to sayMixed or other ethnic backgroundPlease state your biological sex at birth? *MaleFemaleAre you currently pregnant, breastfeeding, or planning a pregnancy in the next 3 months? *YesNo These medications are not suitable in pregnancy, breastfeeding or if you are trying to conceive. If you are sexually active, we advise contraception when taking this medication. This should be a non-oral contraception (e.g. condoms or the coil) if using Mounjaro. If you're taking oral hormonal contraceptives, you will need to take an additional form of contraception during treatment, due to reduced absorption which can result in oral contraceptives being ineffective. You must contact us if you become pregnant or planning a pregnancy in the next 3 months. Please confirm that you have read and understood the following advice: *Yes I confirm that I understandNo I do not want to continueHave you tried the following to try to lose weight in the past? (Select all that apply) *Dieting/Calorie counting/Increasing activity/ExerciseWeight loss supplementsWeight loss programmesI have not tried to lose weight beforeWhat challenges have you faced when trying to successfully lose weight previously? (Select all that apply) *Losing motivation/consistencyInjury/illnessPoor diet/snackingAnything else Chronic kidney disease with reduced function Liver disease or impairment (cirrhosis, liver transplant, etc.)? Any heart problems (such as heart failure, atrial fibrillation, stroke, etc.) History of pancreatitis (Inflammation of the pancreas) Personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2 (MEN2) syndrome Any form of cancer Type 1 diabetes Eye problems (such as glaucoma, retinopathy, etc.) A history of an eating disorder? (e.g., anorexia, bulimia, binge eating disorder) A history of gallstones, blocked bile flow (cholelithiasis), gallbladder infection (cholecystitis) - if you still have your gallbladder). Or gallbladder surgery in the past 12 months. Chronic malabsorption syndrome (problems absorbing nutrients) An endocrine (hormone) disorder, such as overactive thyroid disease awaiting radioactive iodine or surgery, acromegaly, Addison’s disease, Cushing’s syndrome, congenital adrenal hyperplasia, or a growth hormone disorder Treatment or rehabilitation for excessive alcohol use Any cognitive or memory impairment, such as dementia, that may impact the ability to make decisions Severe digestive conditions, including colitis, ulcerative colitis, Crohn’s disease, or gastroparesis (delayed stomach emptying) Any weight loss procedures or surgery in the last 12 months - such as gastric sleeve, gastric band, gastric bypass, or gastric balloon Epilepsy, or porphyria Do you currently have or have you ever been diagnosed with the following? *NoYes. Please clarifyDo you have any allergies? *NoYes. Please clarifyDo you take any medication (prescribed or otherwise)? If Yes, please list the names and what medical conditions you take these for. It is important to complete this accurately for your safety. For example, ibuprofen for migraines. *NoYes. Please clarify Type 2 diabetes High blood pressure High cholesterol Erectile dysfunction Sleep apnoea Asthma Osteoarthritis Chronic back pain Depression or Anxiety PCOS Fatty liver disease Have or have you ever been diagnosed with the following? *NoYes. Please clarify Amiodarone Carbamazepine Ciclosporin Clozapine Digoxin Fenfluramine Lithium Mycophenolate mofetil Oral methotrexate Phenobarbital Phenytoin Somatrogon Tacrolimus Theophylline Diabetic medication, including insulin Warfarin Are you currently taking any of the following medications? *NoYes. Please clarifyOut of best interest, we need to inform your NHS GP that we have started a new medication for you due to safety and medication interaction concerns. Please provide your GP details below: *No I do not want to continueYes. Name + full address I understand that rapid weight loss and injectable weight loss treatments can raise the risk of pancreatitis and gallbladder issues. If I have severe abdominal pain, vomiting, jaundice (yellowing of the skin), or worsening symptoms, I will seek urgent medical help. I understand that severe diarrhoea for over 24 hours, or vomiting within 3 hours of taking the contraceptive pill, can reduce its effectiveness. If this happens, I will call my GP or 111 for advice. I understand I may need a repeat dose of the contraceptive pill or to use additional contraception I understand that my prescribed weight loss medication should not be combined with other weight loss medications. I recognise that these treatments may affect my mood. If I experience low mood or any mental health issues, I will stop the treatment and consult a doctor immediately. I will contact the clinical team and inform my GP if I experience any side effects from this treatment. Please check you understand and agree to this treatment information: *No I do not want to continueYes I confirm that I understandAre you aged 18 to 74 years old? *YesNo I confirm all answers are provided by me, and will be truthful. I will contact the clinical team if I miss two or more doses. I will be the sole user of the medication. I will read all information provided to me before starting treatment. I will inform the clinical team about any previous, existing or new health conditions, medications, or changes to my medical history accurately as soon as possible. I will stop the medication if I fall pregnant or want to try to conceive, and I will let the clinical team know about this as soon as possible. I understand that weight loss medication can interfere with the effectiveness of oral contraception and agree to use an additional form of contraception during treatment as required. I understand that alongside medication, sustained weight loss results will be dependent on a combination of both a healthy lifestyle and increasing activity I understand that failure to give accurate information may result in a refusal to supply medication, or the supply of medication that is not suitable. Final Declaration - Please tick each box to confirm the following *Yes I acceptNo I do not want to continueConsent *Confirm that the information provided is accurate and consent to its use.Submit
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