Weight Loss for Clinics

1. Patient's Details

This section is about the clinic personal details, your current height/weight etc. And don't forget your targets - we will do our best to get you there!

Clinic:

AJ Hill Aesthetics

Slim Transofrmation

Patient full name:

Patient's date of birth:

Please use the following format 00/00/0000

What was the patient's biological sex at birth?

Male

Female

Patient's Phone Number:

Patient's Email Address:

Patient Residential Address:

Is the delivery address the same as the residential address?

If no, please provide their shipping address. Please note, we can only ship to a UK residential or work address.

Yes

2. Patient's History & Treatment Option

Is the patient taking any medications, including vitamins & supplements?

If yes, please list them.

Yes

Does the patient have any allergies or sensitivities?

If yes, please list them

Yes

Does the patient have any medical conditions?

If yes, please list what they are

Yes

What is the patient's BMI?

Please enter any relevant clinical notes:

For example, if patient has titrated up to relevant dose, if patient is on maintenance dose, under any medical investigations etc.

3. Agreements & Prescription Submission

Please enter requested medication(s), including dose & quantity:

Please enter dosing instructions for the medication:

You confirm the patient has titrated up to the requested dose (if the dose is not the first / starting dose)

Yes

You confirm that as the prescriber / prescribing clinic, you will provide ongoing support and aftercare for the patient as per the Royal Pharmaceutical Society's Prescribing Framework (2016).

Yes

You agree to the Terms & Conditions specified on our website, including but not limited to Terms of Sale, Delivery Policy, Returns & Refunds Policy, and Privacy Policy.

Yes

Please enter Prescriber's Details:

Include full name, registration body & registration number e.g. Dr. Bob Gold, GMC 1547323

By signing this prescription, I agree to the terms of service and to conduct all relevant checks, monitoring and reviews as per the RPS 2016 Prescribing Framework and within the relevant regulatory body's Code of Practice.

Yes

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