Proof of identity.

Please upload a clear copy of your passport or UK driving license

Please upload a photo of your weight reading from your scales. This photo must include a picture of you on the scale and clearly show your weight on the scale. This is required as evidence of your weight.

This photo must include a picture of you on the scale and clearly show your weight on the scale. This is required as evidence of your weight. You can upload more than one photo if necessary.

Are you pregnant? or, are you planning on getting pregnant? Or are you breast feeding?

It is important that our prescriber has clear information on whether you are pregnant or planning a pregnancy, or if you are breast feeding. Some medicines are not suitable in pregnancy and can put you or you baby at risk. By answering this question we will be able to determine which medicine is most suitable for you.

Have you ever previously attempted to lose weight by both diet and exercise?

Do you currently or have you previously used any medication to help you lose weight?

Do you currently suffer with any of the following conditions?

• Thryoid cancer or other thyroid issues
• Issues with absorbing food (such as chronic malabsorption)
• Cancer treatment / End stage renal disease / Significant liver dysfunction
• Severe heart failure / Diagnosis of pancreatitis
• Cholestasis

Do any of the following statements describe your condition?

These conditions are frequently weight-related and may be improved by weight loss.

I have been diagnosed with hypertension (high blood pressure).
I have a heart/cardiovascular condition.
I have elevated cholesterol.
I have pre-diabetes.
I've got osteoarthritis.
I have sleep apnoea.
I suffer from erectile dysfunction.
I suffer from asthma or COPD.
I suffer from fatty liver disease.
I suffer from polycystic ovary syndrome (PCOS)

Have you ever previously been diagnosed or suffer with an eating disorder such as anorexia or bulimia?

Do you or have you ever previously suffered with any kidney or liver impairment or damage?

Have you ever previously been diagnosed with Atrial Fibrillation or any condition related to heart beat rhythm?

Have you ever previously been diagnosed with heart failure?

Do you or anybody in your family have any history of thyroid cancer, any previous thyroid issues or any endocrine issues?

Have you ever been diagnosed with any other medical conditions?

Do you suffer with any allergies?

Do you currently take any medication? This includes herbal remedies and over the counter medication.

Are you currently pregnant, planning a pregnancy or breastfeeding?

Is there any other information you would like to share with our prescribing team?

We strongly recommend that you should inform your GP of any treatment you receive. If we are not able to do this for you. Do you agree to inform your GP yourself.

Do you agree to the following?

• I am between the ages of 18 and 65
• This treatment is for my use only
• I have the capacity to make decisions about my own healthcare
• I have understood all the questions and have answered this consultation truthfully and completely
• I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health
• I will read the patient information leaflet supplied with this medication
• I will contact Rutland Pharmacy and inform my GP if I experience any side effects from this treatment or if there are any changes to my health
• I have read, understood and agree with our Terms and Conditions