Before we begin

Answer a few quick questions so our clinical team can check whether this service may be suitable for you before your consultation. This usually takes 2–4 minutes. Treatment is subject to clinical suitability.

I understand and want to continue.

Question 1 of 20

Full name

Question 2 of 20

Date of birth

Question 3 of 20

Postcode

Question 4 of 20

Email address

Question 5 of 20

Mobile number

Question 6 of 20

Are you completing this for yourself?

Yes No

Question 7 of 20

Current weight (kg)

Question 8 of 20

Height (cm)

Your BMI

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Calculated from the height and weight you entered.

Question 10 of 20

Have you used weight loss injections before?

Yes No

Question 11 of 20

Which injection, what dose, and when was your last dose?

Question 12 of 20

Upload evidence of your previous prescription or supply (optional)

A photo or screenshot helps us approve your order faster. JPG, PNG or PDF accepted.

Tap to choose a file JPG, PNG or PDF — max 10 MB

Question 13 of 20

Do you have any of the following conditions?

Select all that apply.

Question 14 of 20

Are you pregnant, breastfeeding, or trying to conceive?

Yes No

Question 15 of 20

Are you taking any regular medicines?

Yes No

Question 16 of 20

Please list your regular medicines

Include prescription medicines, over-the-counter drugs and supplements.

Question 17 of 20

Do you have any known allergies?

Yes No

Question 18 of 20

Please describe your allergies

Question 19 of 20

What is your main reason for seeking treatment?

To improve my health To improve my confidence or wellbeing Both

Question 20 of 20

Do you confirm that all the information you have provided is accurate and complete?

Yes No

Ready to submit

Your answers will be reviewed by our clinical team. Treatment is only supplied where clinically appropriate.