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    Quick Eligibility Check

    What is your current Weight and Height?

    Weight:

    KgStones & Pounds


    Height:

    CmFeet & Inches


    Your BMI is: --

    Do you suffer from: High blood pressure, prediabetes, diabetes, high cholesterol, heart disease, obstructive sleep apnoea or arthritis?

    YesNo

    Are you aged between 18 and 74?

    YesNo

    Unfortunately, due to safety reasons we would be unable to prescribe any weight loss treatments for you. Please contact your GP for further help.

    Have you ever had an allergic reaction to Mounjaro, Wegovy, Ozempic, Semaglutide, Saxenda, Liraglutide or any other weight loss injections?

    YesNo

    Unfortunately, due to safety reasons we would be unable to prescribe any weight loss treatments for you. Please contact your GP for further help.

    If you have type 2 diabetes, do you take any other medications to control your sugar levels apart from metformin?

    YesNo

    Unfortunately, due to safety reasons we would be unable to prescribe any weight loss treatments for you. Please contact your GP for further help.

    Have you been diagnosed with or had surgery for any of the following?

    • Type 1 Diabetes

    • Diabetic Retinopathy (diabetes affecting the eyes)

    • Hypoglycaemia (low blood sugar)

    • Liver or Kidney Disease

    • An Eating Disorder

    • Heart Failure

    • Gastroparesis (a condition where the stomach takes too long to empty)

    • Severe gastrointestinal disease e.g. inflammatory bowel disease, ulcerative colitis, Crohn's disease

    • Chronic Malabsorption Syndrome e.g. celiac disease

    • Gallbladder, Bile duct, or Pancreas disease

    • Pancreatitis

    • Gastric surgery (bariatric surgery)

    • Growth hormone problem e.g., acromegaly

    • Cushing's Syndrome

    • Surgery in the last 3 months

    • A personal or family history of Medullary Thyroid Cancer (MTC), Thyroid cancer, or Multiple Endocrine Neoplasia 2 (MEN2) syndrome

    YesNo

    Unfortunately, due to safety reasons we would be unable to prescribe any weight loss treatments for you. Please contact your GP for further help.

    Are you taking any of the following prescription medications?

    • Amiodarone

    • Carbamazepine

    • Ciclosporin

    • Clozapine

    • Digoxin

    • Fenfluramine

    • Lithium

    • Oral Methotrexate

    • Phenobarbital

    • Phenytoin

    • Somatrogon

    • Tacrolimus

    • Theophylline

    • Warfarin

    YesNo

    Unfortunately, due to safety reasons we would be unable to prescribe any weight loss treatments for you. Please contact your GP for further help.

    Do you take any medications to treat your thyroid or any steroid medications?

    YesNo

    When you lose weight, or change how you eat- this can affect how well these medications work. Therefore, your GP may need to keep a closer eye on this, including your thyroid levels. Keep taking these medications as you normally would while using weight loss injections. However, by continuing with this form you agree to contact your GP to review these medications once you have started any new weight loss medication and periodically throughout treatment.

    Are you pregnant, breastfeeding or trying for a baby?

    YesNo

    Unfortunately, due to safety reasons we would be unable to prescribe any weight loss treatments for you. Please contact your GP for further help.

    Have you used weight loss injections in the past or are you currently using them?

    No - I will be starting them for the first timeYes- I have used weight loss injections in the past 4 weeksYes- I have used weight loss injections in the past 8 weeksYes- I last used weight loss injections more than 8 weeks ago

    When did you start using weight loss injections and what was your weight before starting?

    DATE STARTED:

    KgStones & Pounds


    Are you happy with your progress?

    I am happy with my progress and have no concernsI am not happy with my progress or I have have concerns e.g. side effects, change in health condition

    Do you understand that:

    • ● First-time users must begin with the lowest dose (starter dose)

    • ● If you've used injections successfully for at least 1 month with no issues, you may step-up to the next dose

    • ● If you're an existing customer but it's been over 8 weeks since your last order with us, you will either have to provide us with a prescription from another provider or re-start on the lowest dose

    • ● If you're a new customer and you're not ordering the lowest dose from us- you will need to provide evidence of a prescription from another provider

    YesNo

    If you need further advice please read our FAQ section.

    Do you have any questions or is there anything you feel is important for us to know before we prescribe your medication?

    YesNo

    Photo Upload

    Photos are confidential and seen only by our clinical team. Meeting these criteria avoids delays:

    • Full body, including your face (no sunglasses or obstructions).

    • Straight-on, facing the camera.

    • Wear one layer of fitted clothing (loose clothing may require resubmission).

    • Well-lit, clear, and glare-free.

    Upload Photo

    ID Upload

    To ensure safe prescribing, please upload a clear, valid photo ID showing your full name and date of birth.

    Your privacy is our priority, and delays may occur if we cannot verify your ID.

    • Accepted Forms of ID:

      • Passport

      • Driving License

      • National Identity Card

    Upload ID

    GP Details

    By providing these details, you consent to us sharing your consultation information with your GP for safety and continuity of care.

    Terms & Conditions

    You understand that Wegovy and Mounjaro are weekly injections administered under the skin (upper arms, stomach, or upper legs). We provide an easy instructional video. You can also book a video consultation with one of our experts before you start for guidance and questions.

    You understand that for the best and safest results, you should start with the lowest dose and gradually increase it each month.

    You understand that if you experience concerning side effects, you can contact a Lotus clinician, your GP, or another healthcare professional. You agree to read about potential side effects in the Patient Information Leaflet.

    You agree to stop treatment and seek urgent medical attention if you experience severe dehydration or symptoms like dark urine, blood in stool/vomit, confusion, or vomiting/diarrhoea lasting over 72 hours.

    You understand that Mounjaro and Wegovy may reduce the effectiveness of oral contraceptives. Use additional non-oral contraception (e.g., condoms) during treatment. Stop Mounjaro at least 4 weeks before trying to conceive and Wegovy at least 8 weeks. If pregnant during treatment, stop and consult your GP.

    You confirm you are not currently pregnant.

    You understand that there may be an increased risk of pancreatitis, gallbladder issues, and gallstones. If you experience abdominal pain, seek medical advice.

    You understand that if you develop a lump in your neck, a hoarse voice, or other unusual symptoms, stop the medication and consult your doctor.

    You understand that injectable weight loss treatments may cause mood changes. If you experience depression or thoughts of self-harm, stop the treatment and contact your doctor.

    You understand that injectable weight loss medications should not be combined with other weight loss medications.

    You understand that for best results, a healthy, reduced-calorie diet and regular physical activity are important. Aim for at least 150 minutes of moderate-intensity exercise each week.

    You will read the patient information leaflet supplied with your medication. If you have allergies or contraindications, you will not take the medication and will contact a Lotus clinician for advice.

    You have disclosed any allergies and medical conditions by completing the general health questions.

    You agree that a Lotus clinician may contact you via email, WhatsApp, or phone to offer advice, suggest treatments, or gather more information for an accurate diagnosis.

    You agree that if your condition is not suitable for treatment, you will receive a full refund and be advised to visit your GP.

    You confirm you are at least 18 years old and reside in the UK at the time of consultation. This treatment is for your personal use only.

    You consent to Lotus informing your GP of any weight loss injection treatments prescribed.

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