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Do you agree and consent to the following?

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.

If not, back to homepage

Full Name *

Email *

Phone *

What ethnicity are you? *

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

Demographic & Personal Details

What sex were you assigned at birth? *

Male
Female

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

What is your Date of Birth? *

What is your height & weight?

Height *

Weight *

Have you been diagnosed with diabetes? *

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'.

any disease

Liver, kidney or heart failure
Pancreatitis
Multiple endocrine neoplasia type 2
Cancer
Type 1 diabetic retinopathy
Personal or family history of medullary thyroid cancer
History of an eating disorder (e.g anorexia, bulimia)
History of gallbladder problems
History of inflammatory bowel disease or gastroparesis

None of these statements apply to me

Please list any other medical conditions you have.

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.

Your answer *

Do any of the following statements apply to you?

I have been diagnosed with a mental health condition such as depression or anxiety.
I have or have an eating disorder such as bulimia, anorexia nervosa, or a binge eating disorder.

Multiple Choice 3

None of these statements apply to me

Please tell us more about your specific diagnosis and how you manage it

Your answer *

Have you ever used any other medications to aid in weight loss?

Ozempic
Saxenda
My Simba
Other

Your Answer

medication

I have never taken medication to lose weight

Are you presently taking this medication? *

How did you respond to the medication, and what led you to discontinue its use?

Your answer *

Can you tell us how long you have been taking this medication, share your experience with it?

Your answer *

Please indicate whether you are presently using any medication, such as prescription drugs, over-the-counter medications, or supplements, by selecting all that are applicable to you. *

I'm on Levothyroxine or Warfarin
I don't take any medication
Other
None

I take more than one prescription medication (if so, please list all medication that you currently take) *

Do you have any known allergies? *

Your answer *

Share with GP

Can you confirm if you would like your NHS GP to be made aware if you are deemed eligible for treatment?

If yes, please provide the appropriate GP details below.

GPA *

GP Name *

GP Email Address *

GP Practice Address *

Based on your answers provided you are not eligible

Weightless requires you to be:

BMI plus 25 if an ethnic minority

BMI plus 27 with obesity related health issues such as diabetes or high blood pressure

BMI plus 30 with no obesity related health issues

If you believe based on the above information you are eligible for the program, please resubmit your answers or book a free consultation with our clinicians.

Resubmit

Book A Consultation

Assessment Submitted Successfully!

Thank you for submitting your assessment. Now, it's time to choose your preferred weight loss medication. Our clinician will review your submission and reach out to you (usually same-day!). If you decide not to proceed or if the clinician determines you are not eligible for treatment, you will receive a full refund.