Weight Loss

Consultation

Please complete one of the forms below to determine your eligibility for various weight loss treatments. Choose between the New Customer Form or the Returning Customer Form.

New Customers

If this is the first time you are placing an order with us then click below to start your Online Consultation.

New Customer Consultation Form

Returning Customers

If you have perviously completed a Weight Loss Consultation before then click below to fill out the shorter consultation form.

RETURNING CUSTOMER CONSULTATION

New Customer Consultation Form

Step 1/6: Start

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Answer these questions to get the most effective clinically proven treatments for you.

Full Name

Date of Birth

Please provide an email address so we can contact you furhter regarding enquiries

Phone number

Please provide a number so we can contact you furhter regarding enquiries

Gender at Birth

Male

Female

Are you breast feeding?

Yes

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?

Yes

Do you drink alcohol or smoke?

Yes

Please provide details

eg: How many cigarettes do you smoke per day and/or how many units of alcohol do you consume per day.

Have you received advice from a weight management counsellor before?

Yes

Have you tried to manage your weight by altering your diet and increasing physical activity?

Yes

Do you have a medical history of any of the following listed below?

Select multiple if needed

Diabetic gastroparesis

Diabetes

Inflammatory bowel disease

Ketoacidosis

Congestive heart failure

Severe renal impairment

Thyroid disease

Pancreatitis

Gall Stones

Dysglycaemia

Hypertension

Dyslipidaemia

Obstructive sleep apnoea

None of these

Please choose the statement that best fits you.

Body weight can impact your mental health, pick one statement that best fits you.

I have been diagnosed with a mental health condition such as depression and/or anxiety.

I have been diagnosed with eating disorders such as anorexia, bulimia and/or body dysmorphia.

I have never been diagnosed with any mental health conditions or eating disorders.

How often do you regularly exercise?

I do not exercise

I exercise 1-2 hours a week

I exercise 3 plus hours a week

Has a low-calorie diet failed to manage your weight in the past?

Yes

Would you object to a low-calorie diet as part of treatment?

Yes

Do you have any liver, kidney or heart problems?

Yes

Please provide some details

Do you know your Body Max Index?

Yes

Please list it below.

Height

State your height in Feet & inches or Cm. PLEASE PICK ONE

Feet & Inches

Please state your height in feet and inches

Feet & In

Please state your height in cm

Weight

State your weight in Stones & lb or Kg. PLEASE PICK ONE

Stones & lb

Please state you weight in Stones & Pounds

Stones & lb

Please state your weight in Kg

What is your target weight?

What weight would you like to be?

What is your blood pressure?

Normal (between 90/60mmHg and 120/80mmHg)

High (140/90mmHg or higher)

Low (90/60mmHg or lower)

Unsure

Do you have any allergies?

Yes

Please provide details

Are you currently using any weight loss products?

I have tried Saxenda injections before

I have tried Ozempic injections before

I have tried Xenical (Orlistat/Alli) capsules before

None of these

Other

Please provide details

Do you have any recent or past medical history of note?

e.g. other medical conditions that you have previously been treated for.

Yes

Please provide details

Do you have a history of any mental illnesses, including anxiety or depression?

Yes

Please provide details

Please list all your current prescription medication including any medication you buy over the counter.

If you do not have any just leave blank

Are you aware that Ozempic is being prescribed 'off-label' for weight loss and what this means?

'Off-Label' use of a medicines involves the use of a medicine that has a marketing authorisation but for an indication (condition), at a dose, via a route or for a patient category (e.g. age) that is not listed in the Summary of Product Characteristics for that medicine (off-label use). If you have any questions please contact us where we'll be happy to discuss further

Yes

Is there any particular treatment you prefer?

Saxenda

Ozempic (Off-Label)

Xenical/Orlistat

Rybelsus (Off-Label)

Other

Please provide details

Do you agree to inform us, your GP or seek appropriate medical attention if you suffer from any persistent hoarseness, sore throat, difficulty swallowing or any lumps in your neck?

Yes

What is your waist circumference? (Measure your waist circumference just above your belly button, breathe out gently and take your measurement. You can repeat this a few times just to be sure)

How did you hear about us?

Please tell us how did you find our website.

Bing

Another Website

Other

Google

Yahoo

Word of Mouth

Please provide details

DO YOU AGREE AND CONSENT TO THE FOLLOWING?

• I am over the age of 18 years and live in the UK.

• I will familiarise myself with the patient information leaflet included with the medication.

• I will report any side effects and changes in my health to Bury Healthcare Online and/or your GP.

• I will contact Bury Healthcare Online and inform my GP if I experience side effects to any treatment, if my medical history changes, if I start any new medications or if I experience any symptoms or my medical conditions change in any way.

• I shall be the sole user of any medication offered to me through this service.

• I confirm all answers are provided by me, and will be truthful.

I agree to the terms and conditions

Returning Customer Consultation Form

Leave this field blank

(This form is for returning customers ONLY)

Please ONLY submit this form if you have ordered from Bury Healthcare Online before. One of our clinician may contact you further via a Telephone consultation for additional information.

1. I have placed an order from Bury Healthcare Online before

DO NOT USE THIS FORM IF YOU HAVE NOT PLACED AN ORDER WITH BURY HEALTHCARE ONLINE BEFORE. Please use the New Customer Form.

Yes

Please use the New Customer Form.

Click here to fill out the New Customer Consultation Form

Returning Customer Consent

I agree that I have previously placed an order with Bury Healthcare Online

2. Full Name

3. Date of Birth

4. Email

Please provide an email address so we can contact you furhter regarding enquiries

5. Phone number

Please provide a number so we can contact you furhter regarding enquiries

6. Do you know your Body Max Index?

Yes

Please list it below.

Height

State your height in Feet & inches or Cm. PLEASE PICK ONE

Feet & Inches

Please state your height in feet and inches

Feet & In

Please state your height in cm

Weight

State your weight in Stones & lb or Kg. PLEASE PICK ONE

Stones & lb

Please state you weight in Stones & Pounds

Stones & lb

Please state your weight in Kg

7. Which treatment are you currently using for weight loss?

Saxenda

Wegovy

Ozempic (Off-Label)

Xenical/Orlistat

Rybelsus (Off-Label)

Other

What strength are you using and for how long have you been using it?

Please provide details

Please provide us with further details

8. Have there been any changes since your last consultation?

I have been experiencing strong side effects or problems with the weight loss medication I have been using

I have had changes in my past Medical History

I have been prescribed new medicines from my GP

I have developed new allergies

I am Pregnant, Planning a pregnancy or Breast Feeding

I have no changes and no concerns with my health

Please provide further details

Please provide us with further details

We highly recommend informing your GP about any new medications you are taking

9. Would you like us to inform your GP about this consultation?

Yes

Please provide us with your GP's Name and Address below

10. Do you agree to inform us, your GP or seek appropriate medical attention if you suffer from any persistent hoarseness, sore throat, difficulty swallowing or any lumps in your neck?

Yes

• I am over the age of 18 years and live in the UK.

• I will familiarise myself with the patient information leaflet included with the medication.

• I understand the risks & side effects

• I will report any side effects and changes in my health to Bury Healthcare Online and/or your GP.

• You allow us to get in touch with you if needed, to ensure appropriateness and safety?

• I accept all the refund and returns policy

• I shall be the sole user of any medication offered to me through this service.

• I confirm all answers are provided by me, and will be truthful.

I accept all the above statements and give consent for the Bury Healthcare Online prescriber to check my NHS Summary Care Records if required?

I agree to the terms and conditions

Please ONLY submit this form if you have ordered from Bury Healthcare Online before. One of our clinician may contact you further via a Telephone consultation for additional information.

Back to Form Options

Weight Loss

Consultation

New Customers

Returning Customers

New Customer Consultation Form

Returning Customer Consultation Form

We’re Here Whenever You Need Us

Email

customerservice@buryhealthcareonline.co.uk

Contact Us

46 Walmersley Road,

Bury, BL9 6DP

0161 2221024

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