Initial Consultation Form

Weight Loss Consultation Form

Please fill in all aspects of this form to the best of your ability. Once completed, one of our medical team will contact you.

Please complete the personal and contact details stage of the form.

Title

First name

Last name

Age

DOB

Phone

Email

Home Address

Postcode

Name and address of your GP

Postcode for your GP

BMI Calculator

Please enter your weight in KG

Please enter your height in CM

1.Please enter the BMI number you have just been given

2. Have you entered your BMI accurately?

Yes No

3. I consent to undertaking a remote consultation

Yes No

4. Have you recently had a blood pressure reading?

Yes No

5. Are you aware of any allergies?

Yes No

6. Are you aware of any hypersensitivity to Liraglutide?

Yes No

7. Are you currently being treated with other weight management products?

Yes No

8. Are you pregnant, planning pregnancy or is there a possibility you may be pregnant?

Yes No

9. Are you currently breastfeeding?

Yes No

If none of these apply to you, please tick none of the above