Weight Loss Consultation

What’s Your Birth Gender? *

Male
Female

Name *

First

Last

Email *

Phone *

What’s Your Date of Birth? *

Have you used this service before? *

I'M NEW
It's been more than 3 months since I've been here
I’m using Boots weight loss medicine

Are you pregnant, planning pregnancy, or is there any possibility that be pregnant? *

Are you Breast-Feeding? *

Do you have any allergies? *

Do you have any eating disorders, or have you had one in the past? *

Are you currently dependent on chronic opiates or opiate agonists (e.g. methadone), or are you going through acute withdrawal (cold turkey)? *

Have you been told by your doctor that you have an intolerance to lactose? *

Do you have liver problems? *

Do you have kidney problems? *

Do you have a condition that causes seizures or do you have a history of seizures? *

Do you have a current or past history of bipolar disorder? *

accurate, can that

Do you have a current or past history of depression? *

Do you have any heart or circulation problems? *

Do you have or have you ever had a condition affecting the circulation of blood in the brain? *

Do you frequently use cocaine or other stimulants? *

Are you usually a heavy drinker? *

Do you have a medical condition or take medication that may contribute to your weight gain? *

Examples include growth hormone deficiency, polycystic ovary syndrome, Cushing's

Are you currently taking any medication (over the counter or prescription)? *

Have you ever had a serious head injury or head trauma? *

Have you been told that you have chronic malabsorption syndrome? *

Have you been told that you have cholestasis? *

Have you been told that you have inflammatory bowel disease or any severe stomach or gut problem resulting in delayed stomach emptying (called gastroparesis)? *

Do you have any problems with your pancreas? *

Enter Your Height in CMs or Feets *

Enter Your Weight in KGs or LBs *

WHICH MEDICINE DO YOU PREFER?

Consistency is key, That’s why we offer 10% off each time you re-order Weight Loss treatment. Please see our Terms and Conditions.
Ultimately it will be a joint decision between you and one of our clinicians on whether a particular medicine is appropriate.

Select Any *

Mounjaro
Wegovy
Xenical

Select Pharmacy *

674 Coventry Road, Small Heath, Birmingham, B10 0UU
105 Barton Street , Gloucester, GL1 4HR
267 Dewsbury Road, Leeds, LS11 5HZ
41 Caldmore Green, Walsall, West Midlands, Walsall, WS1 3RW

Do you agree and consent to the following? You are completing this consultation for yourself and to the best of your knowledge. You will disclose any medical conditions, serious illnesses or operations you have had. You will disclose any prescription medications you are currently taking and agree to use only use one weight loss treatment at a time. You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy. Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life- threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation. *

Please confirm you understand

____

WHICH MEDICINE DO YOU PREFER?

Birmingham

Gloucester

Leeds

Walsall