Name*

First Last

Phone*

Email*

What is your weight? (kg)*

Email

Do you have a goal weight you would like to achieve? If so, please write it below.

Have you experienced an allergic reaction to Wegovy, Mounjaro, Semaglutide, Saxenda or Liraglutide before?*

Yes

No

Have you ever suffered with an eating disorder?*

Yes

No

Are you pregnant, breastfeeding, or trying to conceive?*

Yes

No

Have you been diagnosed with or had surgery for any of the following?*

Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome?*

Yes

No

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?*

Yes

No

Are you taking steroids or medication to treat your thyroid?*

Yes

No

Have you taken injectable weight loss medication in the last 4 weeks?*

Yes

No

Are you currently in the 6th month of continuous treatment with injectable weight loss medication?*

Yes

No

Name of your GP*

First Last

Email of your GP*

Name of GP practice*

Address of your GP*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

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Weight Loss Medication Reissue Form

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