Enter Your Date of Birth

Do any of the following statements apply to you:

• I am currently pregnant
• I am trying to get pregnant
• I am breastfeeding

Have you ever been diagnosed with diabetes?

What diabetes type do you have?

Do any of the following statements apply to you:

• Managed by diet and lifestyle
• Managed with Metformin alone
• Managed under a secondary care provider
• Managed with any multiple medications
• Managed with insulin
• Managed with Sulfonylureas
• Managed with DPP-4 Inhibitors (gliptins)
• You have kidney problems
• Have a recent history of diabetic ketoacidosis (Within the last 6 months)
• With a recent history of hypoglycemia (Within the last 6 months)
• Under current review by your GP for diabetes
• You have Diabetic retinopathy

Please confirm if any of the following statements apply to you:

Do you have any of the following conditions?

• Eating disorder or history of disordered eating
• Gastrointestinal disorders
• Pancreatitis (current or past)
• Active gallstones or cholestasis
• Liver health issues
• Kidney disease
• Cardiovascular disease
• Cancer (including thyroid or endocrine-related)
• History of bariatric or gastrointenstinal surgery
• Mental health concerns

Do you have any of the following conditions?

When did your bariatric operation take place?

Please confirm the following details about your bariatric surgery:

• When did you get the surgery?
• What type of bariatric surgery did you have?
• Were there any post-surgery complications?
• Are you undergoing any ongoing monitoring?
• What was your BMI before your surgery?
• Are you still losing weight?

Please tell us more information about your thyroid surgery:

• What was the outcome of your surgery?
• Was there any ongoing monitoring after the surgery was completed?

Please let us know more about your mental health condition and how it's being managed:

Do you currently have Acute Kidney Injury (AKI)?

When did you have Acute Kidney Injury (AKI)?

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

Please let us know more about any medical conditions you have:

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

• Mounjaro
• Wegovy

Are you still taking Mounjaro?

Are you still taking Wegovy?

Are you experiencing any side effects?

Please tell us more about your side effects:

• What side effects are you experiencing?
• How severe are they?
• How long do they last?
• Any other details that may help us.

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

Please outline any of the allergies you have or any other prescription medication you are taking:

Great news! You are suitable for the following treatment*

Up to 22% weight loss*

Mounjaro 2.5mg

(4 Weeks supply) - £149.99

Contains tirzepatide which works by regulating blood sugar and energy balance levels, helping to reduce appetite and prevent cravings.

Continue

Wegovy 0.25mg

(4 Weeks supply) - £109.00

Contains semaglutide, which mimics a hormone responsible for stimulating insulin secretion and slowing stomach emptying to promote satiety.

Continue

Up to 15% weight loss*

Mounjaro 5mg

(4 Weeks supply) - £149.99

Contains tirzepatide which works by regulating blood sugar and energy balance levels, helping to reduce appetite and prevent cravings.

Continue

Up to 22% weight loss*

Wegovy 0.5mg

(4 Weeks supply) - £149.99

Contains semaglutide, which mimics a hormone responsible for stimulating insulin secretion and slowing stomach emptying to promote satiety.

Continue

Up to 15% weight loss*

Mounjaro 7.5mg

(4 Weeks supply) - £169.99

Contains tirzepatide which works by regulating blood sugar and energy balance levels, helping to reduce appetite and prevent cravings.

Continue

Up to 22% weight loss*

Wegovy 1mg

(4 Weeks supply) - £159.99

Contains semaglutide, which mimics a hormone responsible for stimulating insulin secretion and slowing stomach emptying to promote satiety.

Continue

Up to 15% weight loss*

Mounjaro 10mg

(4 Weeks supply) - £189.99

Contains tirzepatide which works by regulating blood sugar and energy balance levels, helping to reduce appetite and prevent cravings.

Continue

Up to 22% weight loss*

Wegovy 1.7mg

(4 Weeks supply) - £199.00

Contains semaglutide, which mimics a hormone responsible for stimulating insulin secretion and slowing stomach emptying to promote satiety.

Continue

Up to 15% weight loss*

Wegovy 2.4mg

(4 Weeks supply) - £249

Contains semaglutide, which mimics a hormone responsible for stimulating insulin secretion and slowing stomach emptying to promote satiety.

Continue

Up to 15% weight loss*

GP Details

Patient Details