Consultations – Weight Management Clinic

Lets Start…at the Start! Please fill in our consultation form as best you can and tell us a little bit about you . The more information you can provide us the better so we can customise and tailor your weight loss journey to suit you.

Name

Height (Feet-Inches)

weight (Stone-pounds)

Phone

Ethnicity can affect your risk of some conditions.

Ethnicity

ARE YOU CURRENTLY TAKING ANY WEIGHT LOSS MEDICATION?

The following questions will be required as any of the following weight-related illnesses will cause your consultation to be void , meaning we cannot provide you with the medication:

Do you have a weight-related illness?

Are you pregnant, planning to be pregnant, or breastfeeding?

Do you have or have you ever experienced any of the following?

Do you take any of the following medications?

Do you have any of the following medical conditions?