Do you agree and consent to the following?

  • I am over 18 years old and live in the UK.

  • I will be the sole user of any medication offered to me through this service.

  • I confirm all answers are provided by me and are completely truthful.

Are you currently using weight loss medication?

What medication did you last use?

What was the last dose you were prescribed?

When did you last use your medication?

What are your main reasons for wanting to lose weight?

What is your height and weight?

Do you have a goal weight you would like to achieve?

What is your goal weight?

What is your biological sex?

Are you pregnant, breastfeeding or trying to conceive?

How long have you struggled with your weight?

What have you tried in the past to lose weight?

What challenges have you faced with exercise or trying to be more active?

What challenges have you faced when changing your eating habits?

What challenges have you faced when trying to stay on track with your weight loss?

Do you suffer from any of the following?

  • Severe Liver or kidney impairment

  • Heart failure

  • History of Pancreatitis

  • Multiple endocrine neoplasia type 2

  • Active cancer

  • Type 1 diabetes or diabetic retinopathy

  • Personal or family history of medullary thyroid cancer

  • A current eating disorder or a history of an eating disorder? (e.g., anorexia, bulimia, binge eating disorder)

  • History of gallbladder problem

  • History of Inflammatory bowel disease or gastroparesis

Have you been diagnosed with any of these medical conditions?

  • Type 2 diabetes

  • High blood pressure

  • High cholesterol

  • Erectile dysfunction

  • Sleep apnoea

  • Asthma

  • Osteoarthritis

  • Chronic back pain

  • Depression

  • PCOS

  • Fatty liver disease

Are you taking any of the following medications?

  • Insulin

  • Sulfonylureas e.g., gliclazide

  • Orlistat

  • Warfarin, Flecainide, Digoxin, Methotrexate

  • Tacrolimus, Ciclosporin, Rifampicin

  • Lithium

  • Phenytoin, Carbamazepine, Valproic acid

Are you taking any other medications?

Please list your current medications, their strengths, and what you take them for.

Please note: If you're currently taking a GLP-1, e.g. Wegovy, you will be required to provide documentation (i.e., a copy of the previous prescription/invoice or a photo of the medication box with the dispensing label showing your name and the dispensing date) to either remain or up-titrate to the next higher-strength medication. You will be prescribed the initial starting strength pen if documentation is not provided.

Do you have any allergies?

Are you allergic to any of the following?

  • GLP-1 Medication, including Rybelsus, Saxenda, Ozempic, Trulicity or Victoza

  • Tirzepatide(Mounjaro)

  • Orlistat

  • Salcaprozate sodium

  • Povidone K90

  • Cellulose, microcrystalline

  • Magnesium stearate

When considering treatment options, which of the following are important to you?

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