To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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Born male
Born female


Please select either Metric or Imperial measurements :

Metric (Centimetre and Kilograms)
Imperial (Feet and Pounds)



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Yes
No
Not Applicable

• Type 2 Diabetes
• Diabetic gastroparesis.
• Inflammatory bowel disease.
• Ketoacidosis.
• Congestive heart failure.
• Obesity secondary to endocrinological or eating disorders or to
treatment with medicinal products that may cause weight gain.
• Severe renal impairment.
• Severe hepatic impairment.
• Pancreatitis.
• Cholelithiasis and cholecystitis (past or present)
• Thyroid disease or medullary thyroid cancer (past or present)
• Depression & suicidal thoughts (past or present)
• Any eating disorders


Such as Ozempic or Saxenda





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  • This treatment is solely for your own use
  • You will read the manufacturer’s patient information leaflet and stop and report and adverse effects immediately to the relevant healthcare professional
  • Y0u confirm that you have answered all the above questions accurately and truthfully. You understand our team take your answers in good faith and base their decisions accordingly, and that incorrect information can be hazardous to your health.

Please state your registered GP if you haven't done so already when signing up 



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