📞 (+44) 07770 474443 . ✉ enquiries@mmsclinic.co.uk

Part of MMS Clinic Group – Doctor‑Led Online & In‑Clinic Services

Part of MMS Clinic Group – Doctor‑Led Online & In‑Clinic Services

Free Discovery Call
Weight Loss

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
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.