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

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Please use the following format 00/00/0000


Male
Female

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Asian or Asian British
Black, African, Caribbean or Black British
Middle Eastern
Mixed or multiple ethnicities with an Asian, Black or Middle Eastern background
White
Other ethnic group
Prefer not to say

Please select either Metric or Imperial measurements :

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

Please stipulate if your measurement is in CMs (centimetres) or INs (inches) or unknown.


Only .jpg, .jpeg, .png, and .gif formats are allowed.(10MB file size limit)

Only .jpg, .jpeg, .png, and .gif formats are allowed.(10MB file size limit)


Only .jpg, .jpeg, .png, and .gif formats are allowed.(10MB file size limit)

Please provide your GP's name, surgery name and address if you consent to us informing them of your treatment.




Let's talk. This section is all about your current lifestyle and your medical history. Anything you feel we need to know, pop it here.

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0-4 hours per night
5-8 hours per night
8 hours or more per night

0
1-3
4-6
7+

If yes, how often?

0 units per week
1-5 units per week
6-10 units per week
11-14 units per week
15+ units per week


If yes, please describe:


If yes, what methods did you use (e.g., diet, exercise, medications)?


If yes, please list them.


If yes, please list them.


Type 1 Diabetes
Type 2 Diabetes
Diabetic Induced Gastro-Paresis
High Blood Pressure
High Cholesterol
Inflammatory Bowel Disease
Kidney / Renal Disease or Impairment e.g. AKI, CKD
Kidney Failure
Pancreatitis
Thyroidectomy or Hemi Thyroidectomy
Thyroid Cancer (Medullary Thyroid Carcinoma)
Family History of Thyroid Cancer (MTC)
Multiple Endocrine Neoplasia Syndrome Type 2
Family History of MEN2
None of the above

Anxiety
Depression
Hypothyroidism (underactive thyroid)
Hyperthyroidism (overactive thyroid)
Anorexia
Bulimia
None of the above

If yes, please provide details:




Please take the time to carefully read the information - this is the nitty gritty stuff. Understanding the information is key - if you are unsure of anything, please get in touch with us via email or telephone.  statements is essential for your safety and for ensuring that you are fully informed about the treatment you will receive. By reading and agreeing to these terms, your informed consent is given for potential treatment - this allows us to give you the best possible care.

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Side Effects:

Like with any new medication, there is the potential for you to experience side effects. The most common side effects may include:

Nausea

Headaches

Dry Mouth

Constipation

Loose Stool

Tiredness

Stomach Cramps


Further information is available via the medication information page.

Adverse Effects:

Adverse effects are rare. They may include:

Palpitations / Fast Heart Rate

Pancreatitis

If you experience or feel that you may be experiencing these adverse effects, please stop using the medication & contact 111 to seek medical help. Please always read the Patient Information Leaflet that comes with your medication for more detailed information. You can also download a copy of the Patient Information Leaflet from the My Account section of the website.

Anaphylaxis:

Whilst there are no documented cases of an anaphylactic reaction to these medications, if you experience swelling of the lips/tongue/throat, difficulty breathing, tightness in the chest, a severe rash or severe itching, discontinue use immediately and call 999.

I am aware of the potential side effects and interactions of the prescribed medication for weight loss.


I understand that the information provided in this assessment will be reviewed by a UK licensed prescriber and/or a pharmacist before my order is processed. 

I consent to my personal and medical information being used and / or share ONLY for the use of assessing my suitability for the prescribed medication.

I understand that my information will be kept confidential, and only shared with my GP if I consent to do so.


I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have implications for my own health & wellbeing.

 

I understand that the information provided in this assessment will be reviewed by a licensed prescriber and/or a pharmacist before my order is processed. 

 

I understand that not following nutritional guidance, drinking alcohol or not reducing calorie intake may reduce my chance of losing weight.

 

I agree to take the medication as advised and directed, ensuring I will keep the medication out of reach of children & only use it for myself

 

I understand that once dispatched, the medication cannot be refunded as per our Terms & Conditions

 

I will seek urgent medical assistance if I experience anaphylactic shock

 

I will contact My Health & Wellness if I need help, support or guidance, or if I experience any side effects

 

I understand that the medication does not guarantee weight loss and results may vary based on a multitude of factors, including but not limited to the medication, diet, nutritional intake and exercise.

 

I agree to read all available literature provided by My Health & Wellness prior to commencing onto treatment.