Please answer the following questions truthfully. If you get stuck or need any help, use our CHAT button below or give us a Call on 01639 502860

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Male
Female
Transmale (Born a female)
Transfemale (Born a male)

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Presently Pregnant
Presently Breastfeeding
Planning on getting pregnant
Neither Pregnant nor Breastfeeding
Does Not Apply

If you're not sure provide and estimate as we can check this before a prescribing decision is made

Please select either Metric or Imperial measurements :

Metric (Centimetre and Kilograms)
Imperial (Feet and Pounds)

If yes please provide more details

If Yes please provide more details on how many units per week and usually when consumed

  • Heart condition
  • High blood pressure
  • Stroke
  • Liver disease
  • Kidney problems
  • Bowel Disease
  • Pancreatitis
  • Gall Bladder disease
  • a suppressed immune system
If yes please provide more details

If yes is this Type I or II?

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Please list all your current prescription medication, medicines you buy including any herbal medicines and recreational drugs if taken.

If you do, what is your current dose, how long have you taken that dose and when was your latest thyroid blood test?

If you do, please tell us which medication you take.

If yes, please provide details



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Please provide more information

You can provide numbers or a vision of what you'd like to achieve

e.g. I live with 2 people and a cat, am a painter and decorator

If yes please provide more details

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  • You will read the patient information leaflet supplied with your medication.
  • You will use the medicine only as directed
  • The treatment is solely for your use.
  • You have answered all the questions accurately and truthfully.
  • You understand incorrect information can be hazardous to your health.

We advise you to share this treatment with your doctor so they can update your medical records. Please provide their address if appropriate.