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Canary Wharf and Birmingham! New patient in-clinic GP appointment only £20! Use code NEW2023 when booking.

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  • Medical
    • GP Consultations
      • GP Consultations
      • Health screens
      • Ear Wax Removal
      • Weight Loss
      • Joint Injections
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      • Mole Checks
      • Cryotherapy & Wart Removal
      • Minor Skin Surgery
      • Facial Aesthetics
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Struggling to lose weight? Join our waiting list! Start your free eligibility assessment here.

    Your journey starts with completing a questionnaire that will be reviewed by one of our GPs. Please complete the information as accurately as possible, so we can assess your suitability for our programme.

    The information you submit is safe. Data you send via this form is encrypted and is stored securely on MyHealthcare Clinic servers. Remember, your responses will be kept confidential.

    Your details

    Your contact details

    Date of birth

    Please indicate preferred contact method

    What measurement would you like to use?

    What is your height in cm?

    What is your height in feet and inches?

    What is your current weight in kg?

    What is your current weight in stone and pounds?

    What sex were you assigned at birth?

    Are you pregnant, breastfeeding or trying for a baby?

    Please note that our treatment programme is not suitable for use while breastfeeding, pregnant, or currently trying for a baby.

    What is your ethnic background?

    Why we ask for your ethnic background? Individuals with ethnic backgrounds face a higher likelihood of weight-related health issues even at a lower BMI. Our medical professionals consider this factor when evaluating the appropriateness of your treatment.

    How would you rate your physical fitness?

    How many hours of physical activity do you do per week?

    eg. gym, running, swimming or team sports

    Have you been diagnosed with or experienced any of the following?

    Please choose all that apply

    Please choose all that apply

    Do you take any medications?

    Have you ever taken any medication for weight loss?

    Do you have any allergies?

    How would you rate your mood in the last 2 weeks?

    Please select any that are true for you

    Would you like to inform your GP about this treatment?

    Please share the name of your GPs surgery


    By submitting this form, you agree with the storage and handling of your data by our team. Please wait for the form to refresh after pressing submit.

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