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1. Do you agree and consent to the following?

I am over 18 and live in the UK.
I will be sole user of any medication offered to me through this service.
I confirm that all answers provided by me are entirely truthful and accurate.
You will disclose any medical conditions, serious illnesses or operations you have had.
You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy.

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2. Contact Information

Full Name *

Email *

Phone *

3. Demographic & Personal Details

What ethnicity are you? *

Asian or Asian British
Black, Black British, Caribbean, or African
White
Mixed
Arab
Other
Prefer not to say

What sex were you assigned at birth? *

Male
Female

4. Fertility & Wellness

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

Our program isn't recommended during pregnancy, while trying to conceive, or while breastfeeding. We recommend speaking with your GP, who can guide you toward safe and suitable weight loss options during this time.

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What is your Date of Birth? *

Our weight loss program is designed for adults, so it's not recommended for those under 18. If you're looking for support, we suggest speaking with your GP—they can help you explore other safe and effective options for reaching your goals.

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5. Height & Weight

Height *

Weight *

BMI Value

You are currently not eligible to complete this form because your BMI is below 19.
We encourage you to reach out to us to discuss personalized options and ensure the safest approach for your needs.

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6. Diabetes Screening

Have you been diagnosed with diabetes? *

Type 2 diabetes and take Metformin
Type 1 or Type 2 diabetes and take medication other than Metformin
I have diabetes but diet controlled
I do not have diabetes

7. BMI Qualifications

Let us know If you have any of the following weight-related conditions, as you may qualify for weight loss medications at a lower BMI. *

On treatment for Depression linked to your weight
Acid reflux or Gastro-oesophageal Reflux Disease (GORD)
High blood pressure
Erectile Dysfunction
Cardiovascular disease (such as heart attack, Atrial Fibrillation)
Knee or hip osteoarthritis
Asthma
COPD
Obstructive sleep apnoea
High cholesterol
Polycystic ovary syndrome (PCOS)
Peri-menopause/Menopause
Other
None of these statements apply to me

8. Medical History

Do you suffer from any of the following?

If yes, please tick the conditions below.

If you do not have any of them, simply state 'None'.

Do you suffer from any of the following?

Liver, kidney or heart failure
Pancreatitis
Multiple endocrine neoplasia type 2
Cancer
Type 1 diabetic retinopathy
Thyroid cancer (personal or family history)
Eating disorders
Gallbladder problems
IBD or gastroparesis
None of these statements apply to me

Based on the health conditions you've indicated, our weight loss program may not be the right fit at this time. We recommend reaching out to one of our specialists to explore safer, more personalized options for your health.

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9. Additional Medical Conditions

Our clinicians need to know your full medical history to make sure treatment is safe for you to take.

Answer “none” if you don’t have any.

Please list any other medical conditions you have. *

10. Mental Health

Have you had: *

Depression/anxiety
Eating disorder
None of these statements apply to me

You are currently not eligible to complete this form due to a history of eating disorders.
We recommend speaking with your GP or a healthcare professional for personalized advice and to explore safe, suitable alternatives that support your well-being.

Think you made a mistake in your assessment form? Click below to fill it out again.

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11. Prior Weight Loss Medication Use

Have you ever used any of the following medications to aid in weight loss? *

Mounjaro
Wegovy
Ozempic
Saxenda
Mysimba
None

Are you still taking it? *

Are you looking for Maintenance dose? *

Yes
No
Not sure

Why did you stop taking it? *

12. Allergies

Allergies noted for safety — not disqualifying unless known drug interaction

Do you have any known allergies? *

What are they? *

13. Current Medications or Supplements

Please indicate what you're currently taking: *

I'm on Levothyroxine or Warfarin
Other
I don't take any medication

Please specify *

14. GP Notification

Would you like your NHS GP to be informed if you're eligible for treatment?

GPA *

GP Name *

GP Email Address

GP Practice Address *

You’re Eligible for this Journey

Weekly injection

Conveniently administered once a week using a pre-filled pen, each containing four doses.

Weight Loss Potential

May support weight reduction of up to 22%
In clinical studies*, participants achieved up to a 22% loss in body weight when the treatment was combined with a low-calorie diet and regular physical activity.

Appetite Control

Helps curb hunger
Formulated with tirzepatide, this medication helps regulate blood sugar and energy levels, which can lead to reduced appetite and fewer cravings.

Checkboxes *

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