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Birthday
Day
Month
Year
Have you been on weightloss medication before?
Yes
No
What is your ethnic background?
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

NHS guidance recognises that healthy weight ranges differ across ethnic backgrounds.

For some groups, treatment eligibility starts at a slightly lower BMI to ensure fair access to care.

Your answer helps us apply the correct BMI threshold when assessing your suitability for treatment.

What was your registered sex at birth?
Male
Female
Do you have any of the following conditions (highlighted below)?
Yes
No

Conditions include:

  • Asthma/COPD

  • Cardiovascular issues

  • Depression and/or anxiety

  • Erectile dysfunction

  • Gout

  • High blood pressure

    • 140/90mmHg or more

  • High cholesterol

  • NAFLD

    • Non-alcoholic fatty liver disease

  • Obstructive sleep apnoea

  • Osteoarthritis

  • PCOS

    • Polycystic Ovary Syndrome

  • Pre-diabetes

    • that doesn't require any treatment

  • Type 2 diabetes

Do you have or have you had any of the following (outlined below)?
Yes
No

Pancreatitis, gallstones, gallbladder disease, Coeliac disease, malabsorption syndrome, Crohn’s disease, ulcerative colitis, gastroparesis, unexplained abdominal pain, diabetes, type 1 diabetes, insulin-treated type 2 diabetes, severe kidney disease, severe liver disease, thyroid cancer, MEN-2, NAION, diabetic retinopathy, diabetic macular oedema, current cancer, severe heart failure, tachycardia, psychosis, paranoia, uncontrolled bipolar disorder, anorexia, bulimia, binge-eating disorder

This includes any substance dependencies – or major procedures including bariatric surgery.

Are you allergic or intolerant to any of the following (below)?
Yes
No

Allergies or intolerances to:

  • Semaglutide

    • e.g Wegovy

  • Tirzepatide

    • e.g Mounjaro

  • Another GLP-1 medication

    • e.g Liraglutide, Dulaglutide, Exanatide, Lixisenatide

This can include your driving license or passport

Clinical consent

I understand and agree to the following:

  • I consent to D H Roberts contacting my GP and accessing my Summary Care Record (or other medical records if required) to verify my medical history and medication eligibility, and to inform my GP of any treatment received. If I don’t have a Summary Care Record I will be required to contact my GP and provide a copy of my medical record.

  • I confirm I have provided honest and accurate information and my order is subject to clinical approval by the clinical team.

  • I confirm that I will read the patient information leaflet, understand the potential risks and side effects and allergies of treatment and agree to discontinue treatment and seek medical attention if severe symptoms occur, and to report all side effects to the D H Roberts clinical team.

  • I confirm to take the medicine as directed and follow appropriate storage instructions that come with it

  • I confirm not to combine doses and / or formulations (taking an extra strength or mixing different strengths to reach a different weekly dose than prescribed). Combining doses can cause dangerous dosing errors which can increase risk of side effects and is not licensed or recommended.


 

By continuing to select a preferred treatment and make a payment, you acknowledge that you have read, understood and agree to all of the above.

What is your preferred treatment?
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