Please enable JavaScript in your browser to complete this form.
Are you currently using any weight loss medication?
This includes tablets or injections that we’ve been prescribing for you, or ones you're getting from another provider.
Have you ever used weight loss medication?
How would you describe your ethnic background? What’s considered a healthy weight can be different depending on your ethnic background. Tell us how you describe yourself so we can ensure you’re getting the right care.
What’s considered a healthy weight can be different depending on your ethnic background. Tell us how you describe yourself so we can ensure you’re getting the right care.
Do you have any of these conditions?

Have you ever had an eating disorder?

For example, bulimia or anorexia. If you think you may have an eating disorder, but have never been diagnosed, please select ‘yes’.

select
Do you have kidney disease?
This might include chronic kidney disease (CKD), polycystic kidneys or kidney failure.
Are you currently pregnant, breastfeeding, or trying to get pregnant?
Are there any other significant illnesses or medical conditions that you haven’t mentioned already? This could be a current or past condition.
Do you currently take any medication, or have you recently finished a course of medication, that you haven't mentioned already? This includes medication you take occasionally or in emergencies.
Are you allergic to any medicines or other substances? For example, peanuts, soya, or other medications (including weight loss medications you’ve previously used).
Your GP | Are you currently registered with a UK GP practice?
We cannot prescribe this medication to you without your GP’s details. We need to let them know about your treatment to ensure you get the best level of care possible.

We cannot prescribe this medication to you without your GP’s details.

We need to let them know about your treatment to ensure you get the best level of care possible

Checkboxes