Weight Management Services

Weight Management

Weight loss support including medication and injections.

Weight loss injections starting from £170 per 4 week cycle. Weight loss capsules £46 per 4 week cycle.

£20 appointment deposit is taken at the end of this questionnaire, which is taken off of the first supply, or refunded in the instance that treatment is unsuitable.

Thank you for contacting. We will respond to you shortly.

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*First Name

*Last Name

*Address

*Postcode

*Phone Number

*Email

*Date Of Birth

*Age

*Gender

Male

Female

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

Yes

NOTICE: This treatment is not suitable if you are pregnant, trying to get pregnant or breastfeeding. We recommend you speak to your GP in person.

*Weight (kg)

*Height (m)

*BMI

*What is your usual blood pressure range?

*Do you suffer from any heart problems?For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.

Yes

*Please give details

*Do you have any thyroid problems?For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.

Yes

*Please give details (thyroid)

*Have you, or anyone in your immediate family ever had thyroid cancer?

Yes

*Please give details (thyroid cancer)

*Do you currently, or have you ever had pancreatitis?

Yes

*Please give details (pancreatitis)

*Do you suffer from any kidney problems?

Yes

*Please give details (kidney)

*Do you suffer from any liver problems?For example: hepatitis, fatty liver, alcohol liver disease etc.

Yes

*Please give details (liver problems)

*Do you suffer from any SEVERE gastro-intestinal problems?For example: inflammatory bowel disease or gastroparesis etc

Yes

*Please give details (gastro)

*Do you suffer with diabetes?

Yes

*Are you taking Insulin?

Yes

*Please give details (insulin)

*Do you suffer from any mental health problems?For example: severe anxiety, severe depression, schizophrenia, personality disorders, body dysmorphia, thoughts of suicide etc.

Yes

*Please give details (mental health)

*Do you suffer with an eating disorder?For example: anorexia, bulimia, binge eating etc.

Yes

*Please give details (eating)

*Do you have any other medical problems?

Yes

*Please give details (problems)

*Are you taking any other medication not already identified above?For example other prescribed medication, products purchased over-the-counter or herbal supplements

Yes

*Please list all medicines and what they treat.

*Do you have any known allergies?

Yes

*Please list your allergies

*It is our policy to inform your GP when patients start prescription medication for weight management. This is to help your GP avoid any interactions with other medications they may prescribe for you. Please tick 'YES' below to give us your permission to do so.

Yes

*Do you smoke?

Yes

*How many per day?

*Do you drink alcohol?

Yes

*How many units per week?Copy and paste this link to calculate your units: https://www.drinkaware.co.uk/sevendaycalculator

*How many cups of tea or coffee do you drink each day?

*How many glasses of water do you drink each day?NB. It is very important to stay hydrated when taking this medication in order to reduce potential constipation

*How many hours of sleep do you average each night?Lack of sleep can affect two important hunger hormones, (ghrelin and leptin) making you feel hungry and increasing your appetite.

*How much exercise / activity do you do each week?NB. This doesn't have to be set time in the gym, it can be ANY activity that gets your heart pumping. (Current guidelines recommend 150 minutes of moderate aerobic activity or 75 minutes vigorous activity per week)

*How many calories do you consume per day?

*Please describe your typically daily diet

*What contributes to your excess weight? (Please tick ALL that apply)

Large portion sizes

Emotional eating

Compulsive eating

Reward eating

Waking and eating at night

Eating out / Takeaways

Medication

Yo-Yo dieting

Snacking between meals

Lack of exercise

Lack of will power

Lack of motivation

Limited mobility

Other

*Please tell us what weight loss interventions you have previously triedFor example: weight watchers, slimming world, increased exercise, went to see GP, medication etc

*Are you currently taking any weight loss treatments such as Mysimba, Saxenda, Wegovy, Ozempic or Phentermine?

Yes

*Which one, and how long have you been taking it?

*Declaration & Consent to TreatmentKindly TICK to confirm that you agree with each of the following statements if you wish to proceed with treatment, then please sign your name below

I have answered all questions truthfully, and I am aware that It is a criminal offense to give false or misleading information about my health

I am over the age of 18

This prescription request is for my own personal use

I will read the patient information leaflet supplied

I agree to follow the dosing schedule prescribed

I am aware that I must combine treatment with a reduced calorie diet and increased physical activity for best results

I agree to record my daily food intake and physical activity

I am aware that there are no guarantees of weight loss using any of these treatments

I understand that if I have not lost 5% of my initial body weight after 12 weeks of being on the licensed dose, I must discontinue treatment

I wish to commence the Programme if I am found to be a suitable candidate following my consultation, and I consent to treatment

Should I experience any changes in my medical history, I will immediately inform the clinic

Signature

Weight Management

Diagnostics

Consultations

Prescriptions

Frequently Asked Questions

How do I transfer my prescriptions to Bute Pharmacy?

What services does the pharmacy offer?

Can I get medical advice without a doctor's appointment?

What should I do if my medication is out of stock?

Do I need an appointment for a consultation?

What vaccinations and health screenings are available?

If you have any other questions, please contact us.