Have you been diagnosed with any of the following?

select which one *

Please confirm if you have had any of the following: *

Gastrointestinal disorders *

Pancreatitis *

Active gallstones or cholestasis *

Liver health issues *

Kidney disease *

Respiratory health issues *

Cardiovascular disease *

High cholesterol (dyslipidemia) *

Cancer *

Bone/joint health issues *

History of surger *

Mental health concerns *

Men health issues *

Do you have any other medical conditions that have not been listed? *

It is crucial that our prescribers know your full medical history to ensure our weight loss plan is safe for you to start .

Please tell us about any other medical conditions you have . *

Have you previously taken, or are taking, any of the following weight loss medication?

any Please

Multiple Choice *

Do you currently take any medication or have any allergies that you have not yet disclosed in this form? *

Please select any of the following statements that apply to you: *

Please list any prescribed medications you are currently taking.

Please clearly list your allergies that you have, and describe any reactions you have experienced.

Please clearly list your medications and allergies that you have, and describe any reactions you have experienced

I have personally completed this medical consultation.
All answers provided are honest, accurate, and to the best of my knowledge.
I have disclosed all prescription medications that I am currently taking.
I will not take this medication alongside any other weight-loss medication.
I have disclosed all relevant medical conditions, allergies, serious illnesses, and past surgeries.
I confirm that I will be the sole user of any medication prescribed through this service.
I understand that I may be prescribed off-label treatment.
I agree to my details and prescription being shared with our pharmacy for dispensing and delivery.
I consent to relevant medical information being shared with my GP if clinically necessary to ensure safe prescribing.
I will use the medication only as prescribed and will read the Patient Information Leaflet provided.
I will inform the service provider if anything changes regarding my health, medications, or medical history.
I accept the service’s Terms of Sale and Privacy Policy.

Checkboxes *