Please fill in the form below and start your weight loss journey. Please enable JavaScript in your browser to complete this form.Name *FirstLastContact Number *Email *What would you like to achieve with weight loss injection?Improve my overall physical healthLose Weight quicklyRebuild my relationship with DietIncrease my confidenceHow Old are you? *Under 1818 to 74Over 75Which ethnicity are you? Healthy BMI ranges are different according to your ethnic background. *Asian or Asian BritishBlack (Caribbean, African)WhiteMixed EthnicitiesOthersWhat sex were you assigned at birth? *MaleFemaleWhats you weight in kg? *Whats you height in cm? * BMI you Have you been diagnosed with diabetes? Diabetes treatments can impact the way the medication included with our weight loss plan works. *I have Diabetes and taking medicine for itI have Diabetes but its diet controlledNo, But there is a history of Diabetes in my familyI am pre-DiabeticI don't have diabetesDo you have any medical conditions or taking any regular medicines? Pharmacist need to know your full medical history to make sure weight loss plan is safe for you.Do you have any allergies or have you ever had allergic reaction to any medicine in the past?Yes i have allergiesNo allergiesWould you like your GP to be informed of this consultation?YesNoSubmit
