Get Started – Weight Loss

Which measurement system do you want to use?

Metric Imperial

Enter Your Height (cm):

Enter Your Weight (kg):

Enter Your Height (ft):

Enter Your Height (in):

Enter Your Weight (lbs):

Your BMI

BMI

Do you suffer from prediabetes, diabetes, heart disease, high blood pressure, high cholesterol or obstructive sleep apnoea?

Yes No

Sorry, We are unable to supply this product to you.

About You

Are you between the ages of 18 and 74?

Yes No

We are unable to supply this product to you.

If you have type 2 diabetes, are you on any injections or tablets to control your blood sugar, other than metformin?

Yes No

We are unable to supply this product to you. Please speak to your GP.

Have you ever suffered with an eating disorder?

Yes No

This treatment is not suitable for you.

Are you pregnant, breastfeeding, or trying to conceive?

Yes No

This treatment is not suitable for you.

Have you been diagnosed with or had surgery for any of the following?
Acromegaly or any growth hormone problem
Chronic Malabsorption Syndrome
Cushings Syndrome
Gallbladder, Bile duct or Pancreas disease
Gastric surgery (bariatric surgery)
Heart Failure
Hypoglycaemia
Kidney Disease
Liver Disease
Pancreatitis
Severe gastrointestinal disease (e.g. inflammatory bowel disease, ulcerative colitis, Crohn's disease)
Type 1 Diabetes

Yes No

We are unable to supply this product to you. We suggest speaking to your GP or nurse about weight loss.

Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome?

Yes No

We are unable to supply this product to you. Please speak to your GP.

Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Are you taking any of the following medications?
Amiodarone
Carbamazepine
Ciclosporin
Clozapine
Digoxin
Fenfluramine
Lithium
Oral Methotrexate
Phenobarbital
Phenytoin
Somatrogon
Tacrolimus
Theophylline
Warfarin

Yes No

We are unable to supply you with treatment. Please consult your GP.

Are you taking steroids or medication to treat your thyroid?

Yes No

Changes to eating patterns can affect the absorption of these medications, so your doctor may need to monitor your thyroid levels more closely. You should continue to take these medications according to your usual routine whilst using, Wegovy or Mounjaro.

Have you taken injectable weight loss medication in the last 4 weeks?

Yes No

Agreement

Do you agree to the following?
You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes No