Rxpress

Weight Loss Treatment Request Form

Full Name:

Date of Birth (DD/MM/YYYY):

Age:

Home Address:

Email:

Telephone:

NHS number (optional):

Name & Address of GP:

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

Health Information

Why are you seeking weight loss treatment?

Have you tried other weight loss methods (diet, exercise, medication)?
YesNo

If yes, please provide details:

Do you have any of the following conditions?
Type 2 DiabetesHigh blood pressureHigh cholesterolPolycystic ovary syndrome (PCOS)Sleep apnoeaNone

Do you currently take any prescription or over-the-counter medications?
YesNo

If yes, please list them:

Have you used any weight loss medications before (e.g. Orlistat, Saxenda, Mounjaro)?
YesNo

If yes, please provide details:

Do you have any allergies?
YesNo

If yes, please specify:

Do you give us permission to access your Summary Care Record or medical records for the purpose of verifying your medical history and appropriateness for treatment?
YesNo

Are you currently pregnant, planning pregnancy, or breastfeeding?
PregnantPlanning pregnancyBreastfeedingNone of these

Please provide any additional information or concerns relevant to your request: