Welcome to Aeternum's Online Weight Management Programme

Our clinician-led weight management service offers personalised treatment, ongoing medical support and convenient access to care from home.

Before getting started, we'll need to learn a little about you.

This secure assessment helps our clinical team understand your health, medical history and weight management goals, so we can determine whether treatment may be suitable for you.

All assessments are reviewed by a qualified prescriber, who may contact you for further information or arrange a consultation before making a treatment decision.

Our programmes start from £115 per month, depending on the treatment recommended.

Your programme includes:

Assessment by a qualified prescriber
Prescribed treatment, where clinically appropriate
Ongoing monthly clinical reviews
Support from our medical team
Medication delivery and access to in-clinic support, where applicable

You'll be able to view our treatment options and current prices once you've completed your assessment.

Completing this assessment is free, carries no obligation to purchase and does not guarantee that treatment will be prescribed.

Let's get started!

Section 1 - About You

First Name *

Last Name *

Phone *

Email *

Address

Street Address

Country

State

City

Postal Code

Date of birth *

Gender:

Male

Female

Are you completing this form for yourself?

Yes

If No, who is helping you? What is your relationship? Why do you require assistance?

Do you have any accessibility requirements or communication needs?

Section 2 - Your GP

GP Surgery:

GP Address including Postcode:

If, following your clinical assessment, you go on to commence a treatment plan with Aeternum, we may need to communicate with your GP as part of providing safe and joined-up care.By continuing, you confirm that you are happy for Aeternum to contact your GP and share relevant information about your care, including details of any treatment prescribed or provided where appropriate.

I understand and consent to Aeternum contacting my GP and sharing relevant information about my care if I commence a treatment plan.

Section 3 - Your Weight Loss Journey

What would you most like to achieve over the next six months?

Have you tried to lose weight through diet and lifestyle changes for at least three months?

Yes

Have you previously received prescription treatment for weight management?

Yes

Are you currently receiving treatment from another provider?

Yes

If yes, please tell us about your experience.

Section 4 - Current Measurements

Height (cm or feet/inches):

Weight (kg or stones/lbs):

Have these measurements been taken within the last seven days?

Yes

What is the highest weight you have been as an adult?

Section 5 - Lifestyle

Which best describes your activity level?

Sedentary

Lightly Active

Moderately Active

Very Active

Do you smoke or vape?

Never

Former Smoker

Current Smoker

Vape only

Section 6 - Medical History

If any of the above are selected, please provide details:

Have you had your blood pressure checked within the last 12 months?

Yes

If yes, please enter your reading if known.

Section 7 - Mental Health

If yes, please provide details:

Do you currently feel under pressure from anyone to lose weight?

Yes

If yes, please explain:

Are you choosing to start treatment of your own free will?

Yes

Unsure

Section 8 - Women's Health

Are you:

Pregnant

Trying to conceive

Breastfeeding

None

Are you taking the oral contraceptive pill?

Section 9 - Medication & Allergies

Please list all medications you currently take.

Please list any vitamins or supplements you currently take.

Do you have any medication allergies?

If yes, please provide details.

Section 10 - Family History

Has anyone in your immediate family been diagnosed with:

Section 11 - Additional Information

Is there anything else you feel your clinician should know?

Final Declaration

Before submitting your assessment, please read and confirm the following:

The information I have provided is accurate and complete to the best of my knowledge.

I understand that providing false or misleading information may result in treatment being refused or discontinued.

Completing this assessment does not guarantee that treatment will be prescribed.

Further information, identity verification and treatment-specific consent may be required before treatment begins.

Where necessary, my relevant information will be shared securely with the dispensing pharmacy to facilitate my treatment.

I have read and understood the above declaration and confirm that the information I have provided is accurate.

Submit Your Assessment

Thank you for completing your initial clinical assessment.

Please sign below and click Submit Assessment to send your information securely to our clinical team.

What happens next?

Our clinicians will review your information and contact you to discuss the next steps, including arranging a video consultation where appropriate.

There is no obligation to proceed, and any treatment recommendation will be based on your individual clinical suitability.

Please sign here:

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