Inital Form – Direct Weight Loss

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About
- About DWL
- Meet The Team
Weight Loss Story
Treatments
FAQs
Contact
Blog
My Portal

Initial Form

To get started on your personalised weight loss journey, please complete the following 6- step form below.

Your honest and accurate responses will help us create a plan tailored specifically to your needs and goals.

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Step 1 of 6

16%

Case ID

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Case ID Admin

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Case Status

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Select Practitioner

1. About You

Please ensure all information is accurate and complete to help us personalise your weight loss plan.

Email(Required)

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Date of Birth(Required)

Day

Month

Year

Age(Required)

Gender(Required)

Female

Male

Are you pregnant, breastfeeding or trying to get pregnant?(Required)

No

Yes

We need to calculate your BMI. Please choose preferred measurement type.(Required)

I will measure in cm/kg

I will measure in ft/st

Height (cm)(Required)

Weight (kg)(Required)

Your BMI(Required)

Height feet(Required)

Inches(Required)

Weight Stones(Required)

Pounds(Required)

Your BMI(Required)

What is your usual blood pressure range?(Required)

What is your ethnicity?(Required)

2. About Your Health

It’s essential that you provide your correct medical history. Honesty is crucial to ensure your safety throughout the programme.

Do you suffer from any heart problems?(Required)

Yes

No

Please give details:(Required)

Do you have any thyroid problems?(Required)

Yes

No

Please give details:(Required)

Have you, or anyone in your immediate family, ever had thyroid cancer?(Required)

Yes

No

Please give details:(Required)

Do you currently, or have you ever had pancreatitis?(Required)

Yes

No

Please give details:(Required)

Do you suffer from any kidney problems?(Required)

Yes

No

Please give details:(Required)

Do you suffer from any liver problems?(Required)

Yes

No

Please give details:(Required)

Do you suffer from any SEVERE gastro-intestinal problems?(Required)

Yes

No

Please give details:(Required)

Do you suffer with diabetes?(Required)

Yes

No

Are you taking Insulin?(Required)

Yes

No

Please give details:(Required)

Do you suffer from any mental health problems?(Required)

Yes

No

Please give details:(Required)

Do you suffer with an eating disorder?(Required)

Yes

No

Please give details:(Required)

Do you have any other medical problems?(Required)

Yes

No

Please give details:(Required)

Are you taking any other medication not already identified above?(Required)

Yes

No

Please list all medicines and what they treat:(Required)

Do you have any known allergies?(Required)

Yes

No

Please list your allergies below:(Required)

GP Name(Required)

GP Address(Required)

GP Phone Number(Required)

3. About Your Lifestyle

Providing accurate details about your lifestyle helps us tailor a plan that fits your habits and goals.

Do you smoke?(Required)

Yes

No

How many per day?(Required)

Do you drink alcohol?(Required)

Yes

No

How many units per week?(Required)

Bottle of lager/beer/cider (5%) 330ml(Required)

How many cups of tea or coffee do you drink each day?(Required)

How many glasses of water do you drink each day?(Required)

How many hours of sleep do you get on average each night?(Required)

How many exercise/activity do you do each week?(Required)

4) Your Weight Loss Journey

Tell us about your past and current efforts to lose weight so we can better understand your journey and provide the right support.

How many calories do you consume per day?(Required)

Please describe your typical daily diet:(Required)

What contributes to your excess weight? (Please tick ALL that apply)(Required)

Large portion sizes

Emotional eating

Compulsive eating

Reward eating

Waking and eating at night

Eating out/takeaways

Medication

Yo-yo dieting

Snacking between meals

Lack of exercise

Lack of will power

Lack of motivation

Limited mobility

Other

Please describe:(Required)

Please tell us what weight loss interventions you have previously tried:(Required)

Are you currently taking any weight loss treatments such as Mysimba, Saxenda, Wegovy, Ozempic or Phentermine?(Required)

Yes

No

Which one, and how long have you been taking it?(Required)

6) Proof of ID

To complete your application, please upload a clear photo copy of your passport photo page or driving licence. Your full name and date of birth must be clearly visible. This helps us verify your identity and ensure that any treatment provided is safe, appropriate, and legally compliant.

Upload Copy of Your ID(Required)

Drop files here or

Max. file size: 128 MB.

5) Declaration & Consent to Treatment

By providing your consent, you acknowledge that you understand and agree to the treatment plan and associated terms below.

Consent(Required)

I have read, agree and consent to the Terms and Conditions of the use of Mounjaro/WeGovy

Please read & tick:(Required)

I have answered all questions truthfully, and I am aware that it's a criminal offence to give false or misleading information about my health

Please read & tick:(Required)

I am over the age of 18

Please read & tick:(Required)

This prescription request is for my own personal use

Please read & tick:(Required)

I will read the patient information leaflet supplied

Please read & tick:(Required)

I agree to follow the dosing schedule prescribed

Please read & tick:(Required)

I am aware that I must combine treatment with a reduced calorie diet and increased physical activity for best results

Please read & tick:(Required)

I agree to record my daily food intake and physical activity

Please read & tick:(Required)

I am aware that there are no guarantees of weight loss using of these treatments

Please read & tick:(Required)

I understand that if I have not lost 5% of my initial body weight after 12 weeks of being on the licensed dose, I must discontinue treatment

Please read & tick:(Required)

I wish to commence the programme if I am found to be suitable candidate following my consultation, and I consent to treatment

Please read & tick:(Required)

Should I experience any changes in my medical history, I will immediately inform Direct Weight Loss clinic

Patient Signature(Required)

Sign Here

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Internal use

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Payment

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Order Created

Invoice Created

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Woo Order ID

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Woo Order Number

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Backend

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Consultation DateTime

© 2025 Direct Weight Loss. All rights reserved.
Direct Weight Loss is a trading name of ePharmaDirect Ltd, a registered UK online pharmacy.
GPhC registration number: 9013128
Registered pharmacy address: Unit 17, Tweed Horizons Business and Conference Centre, Newtown St Boswells, Melrose, TD6 0SG
Tel: 0333 577 1775 | Email: contact@directweightloss.co.uk
Visit our regulator: General Pharmaceutical Council (GPhC)
You can verify our registration on the GPhC Register.

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