Final Online Consultation Form

Welcome to our Online Consultation

To ensure a personalised and unique experience tailored just for you, kindly share a few personal details with us.

PERSONAL DETAILS & VERIFICATION 

We ask for your phone number so that our consultant can give you a call and speak to you about your consultation.

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.

Identity Verification

Please provide a clear and legible photo of yourself holding one of the mentioned identity documents.

  • Birth Certificate
  • Full / Provisional Driving License
  • UK / EU Passport
Select all that apply

Let's Calculate Your BMI

YOUR BMI IS  

YOUR BMI IS which is not suitable for this treatment. 

Select all that apply.

Do you suffer from any of the following?

  • Liver, kidney or heart failure
  • Pancreatitis
  • Multiple endocrine neoplasia type 2
  • 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

Do you suffer from any of these medical conditions?

  • Type 2 diabetes
  • High blood pressure
  • High cholesterol
  • Erectile dysfunction
  • Sleep apnoea
  • Asthma
  • Gallbladder disease
  • Osteoarthritis
  • Chronic back pain
  • Depression
  • PCOS
  • Fatty liver disease
  • Chronic malabsorption syndrome

Are you taking any of the following medications?

  • Insulin
  • Sulfonylureas e.g., gliclazide
  • GLP-1 receptor agonists e.g., Victoza, Saxenda, Wegovy
  • Orlistat
(e.g. Saxenda, Rybelsus, Ozempic, Trulicity or Victoza)

Are you allergic to any of the following?

  • GLP-1 Medication including Rybelsus, Saxenda, Ozempic, Trulicity or Victoza
  • Salcaprozate sodium
  • Povidone K90
  • Cellulose, microcrystalline
  • Magnesium stearate

No Recommended Treatment

Based on your medical history there is no treatment suitable for you. If you think you have made an error in your responses, please go back and review your given answers.
 
Warning: Giving inaccurate information in a clinical consultation, could put your health at risk.

No Recommended Treatment

Based on your allergies there is no treatment suitable for you. If you think you have made an error in your responses, please go back and review your given answers.
 
Warning: Giving inaccurate information in a clinical consultation, could put your health at risk.