Fylde Clinic

Weight Consultation Form

Fylde Clinic weight loss medication consultation form for Mounjaro / Wegovy prescriptions.

Clinically reviewedSecure & confidentialTakes 5–10 minutes

Fylde ClinicStep 1 of 10 — 10% complete

Clinical Assessment

Fylde Clinic weight loss medication consultation form for Mounjaro / Wegovy prescriptions.

Clinically reviewedSecure & confidentialTakes 5–10 minutes

1Getting Started

Are you currently using Mounjaro or Wegovy?*

Yes

Please upload your full body picture. (Kindly upload the most recent picture of yourself in tight clothes from the front)*

Click to upload

PNG, JPG, PDF up to 10MB

Please upload your picture ID Proof (Driving License/ Passport) for Verification.*

Click to upload

PNG, JPG, PDF up to 10MB

GPhC Registered Pharmacy256-bit encryptedMHRA compliant