Consultation Forms | Ask Aesthetics

Patient Notice! This questionnaire forms the basis of your weight loss consultation today. We need you to be honest with your answers including any current medication you are on. This allows our prescribers to make safe clinical decisions and offer accurate advice. We expect you to read the medicinal information provided before selecting your treatment.

Please read the patient information leaflet for Saxenda or Ozempic and understood how to use the medication /injection?

Please watch this instructional video on how to use Saxenda here & Ozempic here

Address (City/ Town )

What is your email address?

*Have you been diagnosed as a diabetic?

Date of Birth (dd/mm/yyyy)

What was your Blood pressure on the last reading (must be in the last 12 months)

Normal 120/80

Low 100/60

Higher 150/100

Have you ever been prescribed this item before?

Do you suffer from any heart conditions?

Yes

What is your Weight? (including units)

What is your height? (including units)

What is your BMI according to your height & weight?

Your BMI should be over 30 to use this medciation, if it is not, it may not be prescriebd for you

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?

If Yes to the above answer, what medications are you taking?

Do you have any known Allergies?

Do you have any history or kidney or liver conditions?

Have you ever been diagnosed with chronic malabsorption syndrome? (problems with absorbing your food)

Have you ever been diagnosed with gallbladder, bile duct or pancreas disease?

Have you ever been diagnosed, or do you currently suffer with an eating disorder such as anorexia or bulimia?

Are you pregnant, planning to become pregnant or breastfeeding?

Do you give us permission to notify your GP of any medication you are prescribed today? It is recommended you allow us to notify your GP of any medication prescribed, so they can maintain a full record of your medications, If yes please type their name and address below:

Do you have a personal or family history of pancreatitis or pancreatic cancer,?

Yes

Have your or a family member ever been diagnosed with thyroid cancer?

Are you fully aware of how to administer this medication?

Do you require the following with your order?

Needles 4mm

Needles 6mm

Yellow Sharps Bin

Please read the leaflet above for Saxenda or Ozempic and confirm you understand how to use the medication /injection?

I Understand I have read the reasons as to why the medication should not be used

I Understand the possible side effects and risks of taking this medication

I Understand the risk of taking more than the recommended dose

I Understand all the potential issues I should consider before using the medication

I Understand this is a cold chan item, & will require temperatures of 2 - 8 degrees of storage immediately upon successful delivery (Fridge)

I Consent to the following:

I confirm I am over 18 years old.

The medicine ordered is for my sole use only

I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances

I understand once a prescription only medicine is issued, a refund cannot be provided as a medicine cannot legally be returned.

Please select a treatment option:

Saxenda

Ozempic 0.25mg (best for beginner)

Ozempic 0.5mg (second order)

Ozempic 1 mg (third or more) ordr

If you experience any side effects that become serious or concern you, please notify your GP or visit your nearest hospital as soon as possible.

Saxenda | Oxempic are new drugs and therefore categorised as 'black triangle'. This means that its safety profile is still being closely monitored. You should report any side effects using the yellow card scheme here.

We can also help you with reporting if you get in touch with us.

Weight Loss Consultation Forms

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