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      Eligibility Check

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      Consent & Choose Treatment

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    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

    Have you ever had an allergic reaction to Orlistat?(brands include Alli, Xenical or Orlos)

    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?

    • Kidney Disease

    • Liver Disease

    • Heart Failure

    • Chronic Malabsorption Syndrome (e.g. celiac disease)

    • Gastric surgery (bariatric surgery)

    • Thyroid problems

    • Gallbladder surgery

    • Cholestasis (blocked flow of bile)

    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?

    • Other Weight loss Drugs

    • Warfarin or other blood thinners

    • Anti-epileptic/ anti-seizure drugs

    • Antidepressants

    • Antipsychotics e.g. lithium

    • Benzodiazepines e.g. diazepam

    • Ciclosporin

    • HIV Medication

    • Iodine salts

    • Amiodarone

    • Acarbose

    • Fat Soluble Vitamins

    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 diabetes, high blood pressure or high cholesterol?

    YesNo

    When you lose weight- this can affect how well medications for these conditions work. Therefore, your GP may need to keep a closer eye on this in case you need to adjust your dosage. Keep taking these medications as you normally would while using weight loss tablets. 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.

    Have you ever been diagnosed with an eating disorder?

    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 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.

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

    YesNo

    GP Details

    By providing these details, you consent to us sharing relevant information with your GP if necessary for safety purposes, accessing your NHS Summary Care Record, or obtaining further details about your medical history.

    Terms & Conditions

    You understand that you need to take a multivitamin containing vitamins D, E, K, and beta carotene while on this treatment. The multivitamin should be taken once a day, at least 2 hours before or after taking Orlistat (Xenical/Alli/Orlos), such as at bedtime.

    You understand that if you gain weight after 3 months of starting this treatment, it cannot be continued.

    You understand that you must stop the treatment if your BMI drops below 28.

    You understand that Orlistat can reduce the effectiveness of oral contraceptives, and that you should use additional non-oral contraception methods (e.g., condoms) during your treatment.

    You understand that weight loss medications should not be used together with other weight loss medications.

    You understand that for the best results with weight loss medications, it is important to follow a healthy, reduced-calorie diet and engage in regular physical activity. This includes aiming for at least 150 minutes of moderate-intensity exercise, such as brisk walking, cycling, or swimming, each week where possible. Your diet should have about 30% of its calories from fat and be rich in fruits and vegetables.

    You are not pregnant.

    You will read the patient information leaflet supplied with any medication we send you and if you have any allergies to any of the ingredients or any contraindications, you will not take the medication and contact a DigiSlim clinician for further advice. You have informed us of any allergies you have by completing the general health questions.

    You have informed us of any current or previous medical conditions you have by completing the general health questions.

    You agree that if needed, a DigiSlim clinician may contact you via email or telephone in response to this consultation form to offer advice and suggest treatments where necessary, or if they feel they need more information to make an accurate diagnosis or assessment of your condition.

    You agree that if after reviewing your consultation, your problem is something we cannot treat or is not suitable for our service, then we will give you a full refund and suggest you visit your registered NHS GP for further advice.

    You are at least 16 years old and currently resident in the UK at the time of this consultation. This treatment is to be used only by you.

    You take responsibility to inform your own regular doctor/ NHS GP of this online consultation and any treatments supplied, or any changes in your circumstances. You agree that DigiSlim will also inform your GP of any weight loss injection treatments we prescribe for you.

    The answers provided to the above questions are true and accurate to the best of your knowledge.

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