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1About You

2Medical

3Summary

4Checkout

Please tell us about your general health.
If you are a new patient, please complete the following questions to help us better understand and treat your condition. Our Clinical Staff will then review your responses and confirm the approval of your treatment. If we can't prescribe you a treatment, no payment is taken.
Patient First Name (full)*
Patient Surname (full)*
Patient's Postcode*

This field is required for patient's age check verification.
Are you a male or female?*
Are you pregnant, breastfeeding or trying to get pregnant?*
- Yes
- No
Saxenda is not suitable if you are pregnant, trying to get pregnant or breastfeeding. We recommend you speak to your GP in person.
What is your date of birth?*
DD dash MM dash YYYY

Your age must be between 18 to 75 years.
Do you confirm that*
- Yes
• You are between 18 to 75 years of age
• You consent to receiving remote/online consultation
• You will answer all questions honestly and understand that it is an offence to provide false information
• You are using the service on your own behalf and of your own free will
• Any treatment/medical advice provided is for you only and based on the information you have provided
• You Consent for us to carry out an automated ID and age verification check during this process.
What is your height?
- Metric
- Imperial
Meter*
Centimeters*
Feet*
Inches*
What is your Weight?
- Metric
- Imperial
KG*
Stones*
Pounds*
BMI*
BMI*
Your BMI is Very Low
If your BMI is between 27-29.9 Saxenda can only be prescribed if you have either previously taken Saxenda and your starting (baseline) BMI was above 30, or if you have at least one co-morbidity. Please confirm one of the following to proceed: *
I have previously taken Saxenda and my starting (baseline) BMI was above 30.
- Yes
I have at least one weight related comorbidity (e.g. diabetes, pre-diabetes, high cholesterol, dyslipidemia, hypertension, sleep apnoea etc)
- Yes
Please state the comorbidities*

Are you currently taking any medicine to help with weight loss ?*
- Yes
- No
Please provide name(s) of medication and dosage*
Do you have a history of MTC (Medullary Thyroid Carcinoma) or have a family history of MTC?*
- Yes
- No
MTC is not a contraindication to Saxenda and clinical studies and evidence to date, no increased risk for MTC has been observed in humans. However, no studies have been carried out which included patients with MTC or a family history of MTC, therefore the effects of Saxenda are unknown in this group. We can therefore not prescribe Saxenda.
Do you suffer from Inflammatory bowel disease?*
- Yes
- No
Saxenda can not be prescribed. There is limited experience in patients with inflammatory bowel disease and diabetic gastroparesis. Use of liraglutide is not recommended in these patients since it is associated with transient gastrointestinal adverse reactions, including nausea, vomiting and diarrhoea
Do you suffer from pancreatitis?*
- Yes
- No
Saxenda can not be prescribed in patients who suffer from, or develop pancreatitis.
Do you previously suffered from heart failure?*
- Yes
- No
Saxenda can not be prescribed. There is no clinical experience in patients with congestive heart failure New York Heart Association (NYHA) class IV, and liraglutide is therefore not recommended for use in these patients.
How many calories do you think you consume daily?*
Do you have, or think you have an eating disorder? This could be Anorexia, bulimia, etc.*
- Yes
- No
Saxenda is not recommended if you suffer from an eating disorder, but please contact us to discuss as there may be other ways in which we can help you without the need of Saxenda.
Are you currently taking insulin or a Sulphonylurea (e.g. Gliclazide or Glimepiride) for diabetes?*
- Yes
- No
Patients taking insulin and/or sulfonylurea have an increased risk of hypoglycaemia. As a precaution, we are unable to prescribe and dispense Saxenda to you .Please speak to your GP
Are you currently taking a GLP-1 (e.g. Victoza, Trulicity, Byetta, Bydureon, Ozemic)?*
- Yes
- No
Please provide the name and GLP-1 you are taking and the dosage*
Saxenda should not be used in combination with another GLP-1 receptor agonist. Inform your GP prior to stopping your previously prescribed GLP-1 and taking Saxenda
Do you have any kidney or liver problems?*
- Yes
- No
Please provide details.*
It is not recommended to use Saxenda if you have severe hepatic or renal impairment as the safety and efficacy of liraglutide for weight management have not been established in these patients.
Have you ever had any cardiovascular (heart problem) or have you ever had a stroke?*
- Yes
- No
Please provide details.*
Do you have any allergies?*
- Yes
- No
Please provide details.*
Are you currently taking any other prescribed or brought medication, supplements or vitamins?*
- Yes
- No
Please provide name(s) of medication and dosage*
Can you think of any other relevant health or medical information that you feel we should know about?*
- Yes
- No
Please provide details.*
I confirm that I have tried to lose weight by diet, exercise and lifestyle changes. I understand that any medication must be used with a healthy diet and exercise regime.*
- Confirm
I confirm that I will seek medical attention and/or inform my GP if I develop any adverse reactions or symptoms, including but not limited to the following: abdominal pain, swelling or a lump in the throat, difficulty swallowing, symptoms of low blood sugar (such as sweating, shakiness, feeling weak), nausea and vomiting which does not settle, an allergic reaction, palpitations or changes to my mood.*
- Confirm
I understand that Saxenda is an injection and confirm that I have viewed the video of how to administer Saxenda and that I feel comfortable to administer this medication myself*
- Confirm
I confirm I understand that Saxenda is a Prescription Only Medication and cannot be returned, unless there is a manufacturer recall on the product or if you have received it faulty. I agree that a faulty product will be returned to the pharmacy in its received form for manufacturers testing and replacements.*
- Confirm
I confirm that I have read the Patient Information Leaflet, understand its contents and will use it only as directed.*
- Confirm
I confirm that I give informed consent to be prescribed medication and I accept London Slimming Clinic’s*
- Confirm

Weight Loss Consultation Summary

General Information

Gender {Are you a male or female?:15}

Are you a male or female?

Pregnancy {Are you pregnant, breastfeeding or trying to get pregnant?:16}

Are you pregnant, breastfeeding or trying to get pregnant?

Date of Birth {What is your date of birth?:17}

What is your date of birth?

You are 18 years or older {Do you confirm that:18}

You are 18 years or older?

Height {Meter:67} m {Centimeters:43} cm

What is your height?

Weight {KG:50} kg

What is your weight?

BMI {BMI:121}{BMI:122}

Your Body Mass index is

Medical Information

Medicine for weight loss {Are you currently taking or have you ever taken any medicine to help with weight loss?:21}

Are you currently taking or have you ever taken any medicine to help with weight loss?

Daily Calories Consumption {How many calories do you think you consume daily?:133}

How many calories do you think you consume daily?

Medication for Diabetes {Are you taking any medication for diabetes, e.g. Insulin, GLP-1 receptor agonists or Sulphonylurea?:26}

Are you currently taking insulin or a Sulphonylurea (e.g. Gliclazide or Glimepiride) for diabetes?

Taking a GLP-1 {Are you currently taking a GLP-1 (e.g. Victoza, Trulicity, Byetta, Bydureon, Ozemic)?:142}

Are you currently taking a GLP-1 (e.g. Victoza, Trulicity, Byetta, Bydureon, Ozemic)?

Kidney or Liver problems {Do you have any kidney or liver problems?:28}

Do you have any kidney or liver problems?

Heart Problem / Stroke {Have you ever had any cardiovascular (heart problem) or have you ever had a stroke?:30}

Have you ever had any cardiovascular (heart problem) or have you ever had a stroke?

Any Allergies {Do you have any allergies?:32}

Do you have any allergies?

Medication, Supplements or Vitamins {Are you currently taking any other prescribed or brought medication, supplements or vitamins?:34}

Are you currently taking any other prescribed or brought medication, supplements or vitamins?

Relevant Health or Medical Information {Can you think of any other relevant health or medical information that you feel we should know about?:36}

Can you think of any other relevant health or medical information that you feel we should know about?
Weight Loss Consultation Summary

General Information

Gender {Are you a male or female?:15}

Are you a male or female?

Pregnancy {Are you pregnant, breastfeeding or trying to get pregnant?:16}

Are you pregnant, breastfeeding or trying to get pregnant?

Date of Birth {What is your date of birth?:17}

What is your date of birth?

You are 18 years or older {Do you confirm that:18}

You are 18 years or older?

Height {Feet:115} ft. {Inches:116} in

What is your height?

Weight {KG:50} kg

What is your weight?

BMI {BMI:121}{BMI:122}

Your Body Mass index is

Medical Information

Medicine for weight loss {Are you currently taking or have you ever taken any medicine to help with weight loss?:21}

Are you currently taking or have you ever taken any medicine to help with weight loss?

Daily Calories Consumption {How many calories do you think you consume daily?:133}

How many calories do you think you consume daily?

Medication for Diabetes {Are you taking any medication for diabetes, e.g. Insulin, GLP-1 receptor agonists or Sulphonylurea?:26}

Are you currently taking insulin or a Sulphonylurea (e.g. Gliclazide or Glimepiride) for diabetes?

Taking a GLP-1 {Are you currently taking a GLP-1 (e.g. Victoza, Trulicity, Byetta, Bydureon, Ozemic)?:142}

Are you currently taking a GLP-1 (e.g. Victoza, Trulicity, Byetta, Bydureon, Ozemic)?

Kidney or Liver problems {Do you have any kidney or liver problems?:28}

Do you have any kidney or liver problems?

Heart Problem / Stroke {Have you ever had any cardiovascular (heart problem) or have you ever had a stroke?:30}

Have you ever had any cardiovascular (heart problem) or have you ever had a stroke?

Any Allergies {Do you have any allergies?:32}

Do you have any allergies?

Medication, Supplements or Vitamins {Are you currently taking any other prescribed or brought medication, supplements or vitamins?:34}

Are you currently taking any other prescribed or brought medication, supplements or vitamins?

Relevant Health or Medical Information {Can you think of any other relevant health or medical information that you feel we should know about?:36}

Can you think of any other relevant health or medical information that you feel we should know about?
Weight Loss Consultation Summary

General Information

Gender {Are you a male or female?:15}

Are you a male or female?

Pregnancy {Are you pregnant, breastfeeding or trying to get pregnant?:16}

Are you pregnant, breastfeeding or trying to get pregnant?

Date of Birth {What is your date of birth?:17}

What is your date of birth?

You are 18 years or older {Do you confirm that:18}

You are 18 years or older?

Height {Feet:115} ft. {Inches:116} in

What is your height?

Weight {Stones:117} st. {Pounds:69} lb

What is your weight?

BMI {BMI:121}{BMI:122}

Your Body Mass index is

Medical Information

Medicine for weight loss {Are you currently taking or have you ever taken any medicine to help with weight loss?:21}

Are you currently taking or have you ever taken any medicine to help with weight loss?

Daily Calories Consumption {How many calories do you think you consume daily?:133}

How many calories do you think you consume daily?

Medication for Diabetes {Are you taking any medication for diabetes, e.g. Insulin, GLP-1 receptor agonists or Sulphonylurea?:26}

Are you currently taking insulin or a Sulphonylurea (e.g. Gliclazide or Glimepiride) for diabetes?

Taking a GLP-1 {Are you currently taking a GLP-1 (e.g. Victoza, Trulicity, Byetta, Bydureon, Ozemic)?:142}

Are you currently taking a GLP-1 (e.g. Victoza, Trulicity, Byetta, Bydureon, Ozemic)?

Kidney or Liver problems {Do you have any kidney or liver problems?:28}

Do you have any kidney or liver problems?

Heart Problem / Stroke {Have you ever had any cardiovascular (heart problem) or have you ever had a stroke?:30}

Have you ever had any cardiovascular (heart problem) or have you ever had a stroke?

Any Allergies {Do you have any allergies?:32}

Do you have any allergies?

Medication, Supplements or Vitamins {Are you currently taking any other prescribed or brought medication, supplements or vitamins?:34}

Are you currently taking any other prescribed or brought medication, supplements or vitamins?

Relevant Health or Medical Information {Can you think of any other relevant health or medical information that you feel we should know about?:36}

Can you think of any other relevant health or medical information that you feel we should know about?
Weight Loss Consultation Summary

General Information

Gender {Are you a male or female?:15}

Are you a male or female?

Pregnancy {Are you pregnant, breastfeeding or trying to get pregnant?:16}

Are you pregnant, breastfeeding or trying to get pregnant?

Date of Birth {What is your date of birth?:17}

What is your date of birth?

You are 18 years or older {Do you confirm that:18}

You are 18 years or older?

Height {Meter:67} m {Centimeters:43} cm

What is your height?

Weight {Stones:117} st. {Pounds:69} lb

What is your weight?

BMI {BMI:121}{BMI:122}

Your Body Mass index is

Medical Information

Medicine for weight loss {Are you currently taking or have you ever taken any medicine to help with weight loss?:21}

Are you currently taking or have you ever taken any medicine to help with weight loss?

Daily Calories Consumption {How many calories do you think you consume daily?:133}

How many calories do you think you consume daily?

Medication for Diabetes {Are you taking any medication for diabetes, e.g. Insulin, GLP-1 receptor agonists or Sulphonylurea?:26}

Are you currently taking insulin or a Sulphonylurea (e.g. Gliclazide or Glimepiride) for diabetes?

Taking a GLP-1 {Are you currently taking a GLP-1 (e.g. Victoza, Trulicity, Byetta, Bydureon, Ozemic)?:142}

Are you currently taking a GLP-1 (e.g. Victoza, Trulicity, Byetta, Bydureon, Ozemic)?

Kidney or Liver problems {Do you have any kidney or liver problems?:28}

Do you have any kidney or liver problems?

Heart Problem / Stroke {Have you ever had any cardiovascular (heart problem) or have you ever had a stroke?:30}

Have you ever had any cardiovascular (heart problem) or have you ever had a stroke?

Any Allergies {Do you have any allergies?:32}

Do you have any allergies?

Medication, Supplements or Vitamins {Are you currently taking any other prescribed or brought medication, supplements or vitamins?:34}

Are you currently taking any other prescribed or brought medication, supplements or vitamins?

Relevant Health or Medical Information {Can you think of any other relevant health or medical information that you feel we should know about?:36}

Can you think of any other relevant health or medical information that you feel we should know about?

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