Weight loss consultation form

    Your journey begins here—let us guide the way!

    To provide the best care, we’ll ask you a few questions to assess your eligibility and customise your treatment plan to suit your needs.

    Rest assured, all your responses will be handled with the utmost privacy and confidentiality, ensuring a safe and personalised experience.

    Customer Journey Outline

    Once you’ve completed this form, our expert team will carefully review your responses and assess whether you’re a suitable candidate for the weight loss injections we offer. Based on the information you provide, we will design a personalised treatment plan specifically tailored to support your health and help you achieve your weight loss goals.

    Here’s what happens next:

    1

    Initial evaluation and eligibility check

    Our team will assess the information you’ve provided to ensure that you’re eligible for the weight loss injections. This process involves evaluating your current health status and previous medical history to ensure the offered treatment aligns with your specific needs.

    2

    Personalised treatment plan

    If you meet the eligibility criteria, our team will create a customised plan. This will include appropriate medication and dosage recommendations based on your needs to ensure the treatment is safe and effective and helps you achieve your desired outcome.

    3

    Ongoing support

    We’ll be with you every step of the way and our team will regularly monitor your progress. If you have any questions or need changes to your plan, we're just a message or call away. Our team is committed to helping you stay motivated, informed, and on track throughout your journey.

    Section 1: Personal details

    Please note, our services and medications are exclusively available to individuals residing in the UK. If you’re based in the UK, we’re here to assist you with expert care and support tailored to your needs


    Please provide your GP details and NHS number

    We require your GP’s details to prescribe this medication and ensure your records are up to date.




    Your Summary Care Record contains important health information to help us provide you with the best care.




    Age plays a key role in determining eligibility for weight loss medication.




    What is your current height and weight?

    We determine your BMI based on your height and weight to evaluate your eligibility for weight loss medication.



    Please enter height and weight

    Section 2: Medical history









    If you are of childbearing potential and seeking weight loss treatment, it is crucial to use effective contraception during the course of this treatment.



    This includes anorexia nervosa, bulimia, binge eating disorder or other eating disorders.






    Please note, if this is your first weight loss treatment and you haven't been prescribed any medication before, you have to initiate treatment at a lower dose with 2.5mg as a starting dose for Mounjaro to ensure your safety and effectiveness of the medication.

    Please note, if this is your first weight loss treatment and you haven't been prescribed any medication before, you have to initiate treatment at a lower dose with 0.25mg as a starting dose for Wegovy to ensure your safety and effectiveness of the medication.

    This includes prescription, over-the-counter, and homeopathic medicines.


    Section 3: BMI verification

    To ensure safe and appropriate treatment, we need to verify your BMI.



    Please upload a full-length photo of yourself that meets these requirements:

    • Full-length view (head to feet)

    • Clear and well-lit photo

    • Should not be blurry

    • Your photo only

    • Wear form-fitted clothing

    • Avoid loose or baggy clothes

    • Hold a piece of paper with today’s date handwritten


    Section 4: Terms and Conditions

    If you agree to the following, you can proceed with your consultation

    • You confirm that you have understood all the questions and have answered them truthfully.

    • You are over the age of 18.

    • You will read the patient information leaflet provided with this medication.

    • You understand that our team may need to access your NHS GP records to safely prescribe this medication.

    • You accept that medication is non-refundable.

    • You agree to contact Batley Pharmacy and inform your GP if you experience any side effects from this treatment.

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