Contact form

Regarding this weight loss consultation, we'll be inquiring about your health and medical background to determine if a prescription is suitable for you. We are asking ethnicity, because metabolic disorders may affect some spesific ethnicities differently.
By proceeding to the next step, you affirm that you:
<ul class="ul1">
<li class="li1"> Are personally filling out this questionnaire and providing information to the best of your knowledge.</li>
<li class="li1"> Will openly share any significant illnesses you have experienced.</li>
<li class="li1"> Will openly share details about any prescription medications you are presently taking.</li>
<li class="li1"> Agree to abide by our Terms &amp; Conditions</li>
</ul>

Your age range

Under 18

18 to 74

Over 74

Phone Number

Your Ethnicity

Asian or Asian British

 Black, Black British, Caribbean, or African

White

 Mixed or multiple ethnic groups

Other ethnic group

Your Gender

Male

Female

Other

Your Height (cm)

Your Weight (kg)

Do You Have Diabetes?

I have diabetes and am currently on medication for it

 I have diabetes and it's diet controlled

I don't have diabetes

Medical Conditions

I'm currently receiving cancer treatment

 I have undergone bariatric surgery

Severe heart failure

 End-stage kidney disease

Severe liver impairment

Personal or family history of thyroid cancer

A history of pancreatitis

 None of above conditions pertain to me

Mental Health

I have received a diagnosis of a mental health disorder, such as depression or anxiety

 I have been diagnosed with or currently experience an eating disorder, such as bulimia, anorexia nervosa, or binge eating disorder