PATIENT CONSENT AGREEMENT

You are completing this consultation for yourself and to the best of your knowledge. You will disclose any medical conditions, serious illnesses or operations you have had. You will disclose any prescription medications you are currently taking and agree to only use one weight loss treatment at a time. You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy. Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life-threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation.

I AGREE

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Please complete this form and send to weight.loss@newgenpharmacy.co.uk. A staff member will be in touch with you shortly.

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Personal Info

Name: Click or tap here to enter text.

Last Name: Click or tap here to enter text.

Phone: Click or tap here to enter text.

Email: Click or tap here to enter text.

Full Address: Click or tap here to enter text.

City: Click or tap here to enter text.

Postal Code: Click or tap here to enter text.

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How old are you?

(?) Persons at or under the age of 18 and over the age of 75 are not eligible for the weight loss treatment. Submissions from individuals below this age will not be regarded.

Under 18 ☐

18 – 75 ☐

75 & over ☐

Date of birth: Click or tap here to enter text.

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What is your ethnicity?

Healthy BMI ranges vary based on ethnic background. Our clinicians will carefully assess your BMI and full medical history to determine the most suitable treatment, which may include off-label prescriptions when clinically appropriate.

☐Black (Caribbean, African)

☐Asian or Asian British

☐Mixed ethnicities

☐White

☐Other (Please specify: )

What sex were you assigned at birth?

☐Male

☐Female

Are you currently pregnant, trying to get pregnant, or breastfeeding?

⚠ Please Note: Women who are pregnant or planning to have a child are not eligible for the weight loss treatment. Submissions from individuals in this category will not go through.

☐Yes

☐No

What is your weight? Please enter your weight in kg or lbs (specify whether it's in kilograms or pounds)

Click or tap here to enter text.

What is your height? Please enter your height in cm or fts/in (specify whether it's in centimetres or feets/inches).

Click or tap here to enter text.

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 take medication for it.

☐ I have diabetes and it's diet-controlled

☐No, but there is history of diabetes in my family

☐I have pre-diabetes

☐I don't have diabetes

If you chose “ I have diabetes and take medication for it.” please tell us more about your mental health condition and how you manage it. Click or tap here to enter text.

Do any of the following statements apply to you?

These conditions can lead to serious complications when losing weight or taking weight loss medications.

☐I have chronic malabsorption syndrome (problems absorbing food)

☐I have cholestasis

☐I’m currently being treated for cancer

☐I have diabetic retinopathy

☐I have severe heart failure

☐I have a family history of thyroid cancer and/or I’ve had thyroid cancer

Do any of the following statements apply to you?

☐I have end-stage kidney disease

☐I have Multiple endocrine neoplasia type 2

☐I have a history of pancreatitis

☐I have or have had an eating disorder such as bulimia, anorexia, or a binge eating disorder

☐I have had surgery or an operation to my thyroid

☐I have had a bariatric operation such as gastric band or sleeve

☐ None of these statements apply to me

Do any of the following statements apply to you?

These conditions are often weight related and may be improved as a result of losing weight.he following statements apply to you?

☐I have a family history of thyroid cancer and/or I’ve had thyroid cancer

Please tell us more about your mental health condition and how you manage it Click or tap here to enter text.

☐My weight makes me anxious in social situations

☐I have joint pains and/or aches

☐My weight makes me anxious in social situations

☐ I have joint pains and/or aches

☐I have osteoarthritis

☐I have GORD and/or indigestion

☐I have a heart/cardiovascular problem

☐I have menopausal symptoms

☐I have polycystic ovary syndrome (PCOS)

☐None of these statements apply to me

☐I have fatty liver disease

☐I have sleep apnoea

☐I have asthma or COPD

☐I have erectile dysfunction

☐I have low testosterone

☐I’ve been diagnosed with, or have a family history of, high blood pressure

☐I’ve been diagnosed with, or have a family history of, high cholesterol

Do you have any other medical conditions?

Our clinicians need to know your full medical history to make sure our weight loss plan is safe for you.

☐Yes

☐No

If Yes, Please list any other medical conditions you have.

These conditions can lead to serious complications when losing weight or taking weight loss medications

Click or tap here to enter text.

Have you ever taken any of the following medications to help you lose weight?

These conditions can lead to serious complications when losing weight or taking weight loss medications.

☐Wegovy

☐Ozempic

☐Saxenda

☐Rybelsus

☐Mounjaro

☐Alli

☐Mysimba

☐I have never any taken medication to lose weight

☐Other

Please specify the other medications to help you lose weight.

What was your weight in kg before starting your previous medication? Click or tap here to enter text.

When was your last dose of?

☐Less than 4 weeks ago

☐4-6 weeks ago

☐More than 6 weeks ago

What dose were you prescribed most recently?

☐0.2mg

☐0.5mg

☐1mg

☐1.7mg

☐2.4mg

☐Other

If you want to continue, what dose would you like to continue with?

A clinician will review your answers and select your dosage as appropriate. Price varies by dosage.

☐Increase my dose

☐Keep my dose

☐Decrease my dose

Have you experienced any side effects?

☐Yes

☐No

If Yes, Please list any other medical conditions you have.

Please give us the type of effect, duration, severity and whether they have resolved.

Do you currently take any other medication or have any allergies?

This includes prescribed medication, over-the-counter medication, and supplements. Select all that apply to you. It’s important we know about any medication so that we can make sure there are no complications.

☐I’m on levothyroxine

☐I’m on warfarin

☐I don’t take any medication

☐Other / I take more than one prescription medication

Would you like your GP to be informed of this consultation?

To ensure we provide the best and safest service for you, we strongly encourage you to share your GP details so we can inform them about your treatment.

☐Yes

☐No

Gp’s First Name:	Click or tap here to enter text.	Gp’s Last Name:	Click or tap here to enter text.

Gp’s Postcode:	Click or tap here to enter text.	Gp’s Email:	Click or tap here to enter text.

Weightloss Treatment

These fees include doctor’s consultation, prescription & delivery, No needles. Tick the dosage you would like to purchase.

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Mounjaro Weightloss Injections

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Wegovy Weightloss Injections

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Please complete this form and send to weight.loss@newgenpharmacy.co.uk. A staff member will be in touch with you shortly.