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Medical Weight Management Request Form

Confidential • Clinically reviewed • Evidence based

For injectable treatments: Mounjaro, Wegovy, Ozempic, Saxenda — and oral Orlista and MySimba
All questions must be completed to assess suitability and ensure patient safety.
Submitting this form does not guarantee treatment
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Step 1 of 8



1. About You

1.4 Gender: *
1.13 Ethnicity (tick one): *
1.14 Required Uploads: *

2. Weight-Loss History, Treatment Preference & Goals

2.1 Which treatment are you interested in? (tick one) *
2.2 What are your main reasons for wanting to lose weight? (tick all that apply) *
2.3 What is your approximate weight-loss goal? (tick one) *
2.6 Have you previously used medical weight-loss treatments? *

(e.g. Orlistat, Mysimba, Mounjaro, Wegovy, Ozempic, Saxenda or others)

2.7 Have you ever had weight-loss (bariatric) surgery? *

(e.g. gastric band, sleeve, bypass, balloon)

3. MEDICAL HISTORY – SAFETY SCREENING

Have you ever been diagnosed with, or do you currently have, any of the following? (Please tick all that apply and provide details below.)

3.2 Weight-Related Health Conditions

Have you been diagnosed with, or do you currently experience, any of the following conditions? (Please tick all that apply)

4. CURRENT MEDICATIONS & ALLERGIES

5. REPRODUCTIVE HEALTH (for women / people with a uterus)

5.1 Are you currently pregnant?
5.2 Are you currently breastfeeding?
5.3 Are you planning a pregnancy in the next 3 months?
5.4 Are you using reliable contraception if sexually active?

(Note: some treatments may reduce the effectiveness of the oral contraceptive pill. You may be advised to use additional contraception.)

6. LIFESTYLE & SUBSTANCE USE

6.1 How would you describe your daily fluid intake? (Hydration is important during weight-loss treatment)
6.2 Smoking status (tick one):
6.3 Estimated alcohol intake per week (tick one):
6.4 Have you ever received treatment or rehabilitation for alcohol use?
6.5 Do you currently use any illicit or recreational drugs (e.g. cocaine, amphetamines)?
6.6 Do you use any opioid medicines (e.g. codeine, tramadol, morphine, methadone, buprenorphine)?

7. GP DETAILS & CONSENT

7.5 Do you consent to us notifying your GP that you are starting medical weight-management treatment? *

For your safety, it is our clinical policy to inform your GP when prescription weight-loss medication is started. This helps prevent drug interactions and supports joined-up care.

8. DECLARATION & AGREEMENT

Please tick to confirm each statement:

By typing my name below, I confirm that the information provided is correct, and I consent to assessment for medical weight management treatment.

More Services

The sections below provide further details on available services and associated fees. All treatments are subject to clinical assessment and suitability.

Home Visit
Within 20 miles of Coventry (09:00–22:00): £279

Patients requesting a home visit are required to book an initial telephone consultation (£45). If the home visit proceeds following this assessment, the £45 fee will be deducted from the home visit cost.

  • Injection volume under 2 ml: £250

  • Injection volume over 5 ml: £300

Simple Skin Lesions
Skin tags, seborrhoeic warts, simple moles, lipomas under 1 cm:
£250 per lesion

Large or Cystic Lesions
Epidermoid, pilar, sebaceous, or ganglion cysts, large lipomas:
£350 per lesion

Additional Lesions

  • Additional skin lesion: £50

  • Additional cystic lesion: £100

Ingrown Toenail Surgery
£379 per toe

Histology
All pigmented lesions must be sent for histology or at clinical discretion or patient preference:
£100 per sample

Blood tests, allergy testing, STI screening, cultures, swabs, and imaging referrals are available where clinically appropriate.

Prices depend on the tests required and will be discussed following telephone, video, or face-to-face assessment.

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Common Questions

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We are here to assist you with any questions or concerns you may have. Feel free to reach out to us anytime

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