PATIENT REGISTRATION FOR MEDICATION

Date

DayMonthYear
Thank you for your interest in my weight loss services. I am passionate about providing a safe and high-quality service, in keeping with my responsibilities as a medical doctor.

Once you are ready to start medication, please complete the following registration form which is required for professional clinic records before issuing of prescriptions.

I may have only recently seen you in clinic, or you may have spent some considerable time thinking about medication, so apologies for any repetition, but I need to ensure I have up-to-date information from you, at the time that you confirm you wish to proceed with medication.

Thank you.
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Email*
example@example.com
Email*
Mobile number (required for delivery of prescription)*
Please check number is correct
Face to face +/- onlineOnline only
VERIFIED HEIGHT AND WEIGHT MEASUREMENT

If you wish to start weight loss medication under my care, my ethical and professional obligations require me to confirm the accuracy of your height, weight and BMI so that I can provide you with the safest and most appropriate care.

I would normally verify this during a face-to-face consultation, in the NHS or privately. However, for online consultations, I am required to ask you for photographic evidence to comply with national CQC regulations for medical services.

Unfortunately, many unscrupulous providers, are not complying with regulations and are issuing drugs to anyone, with no proof that they are actually overweight. This unsupervised and inappropriate prescribing can actually make longterm weight control harder, can be dangerous, and raises concerns about the safety of their practice and their sourcing and handling of medication in general.

It also detracts from the potential of these valuable new drugs to make a real impact on the health and weight of so many people, and risks wasting their money, which saddens me.

Please upload photos to provide evidence of your height and weight using the link below.

Wearing fitted clothing e.g. lycra will also allow me to assess your body shape, as I would do in my hospital clinic. This will provide me with more insight on your health risks. A side profile photo will therefore help too.

Please provide:
Please upload photo with evidence of height*

Cancelof
Please upload photo with evidence of weight*

Cancelof
Please upload side profile image*

Cancelof
Current weight in kg*
Please check your answer is correct
Current height in metres*
BMI*
Please also provide your current waist and hip measurement as a starting point to assess health and weight improvements on medication.
Waist measurement in cm*
Hip measurement in cm*
Waist to hip ratio:*
Please record any current medication and dose or enter NONE*
Please record any any current allergies or enter NONE*
You have already provided me with your medical history. Please note any new changes or enter NONE*
You should have received a consent form via a separate link (please check spam). Please read and e-sign if you have no further questions.

Otherwise, please contact me via contact@drsallynorton.com and I will answer any other questions you may have.
Yes, all signed.No, not yet signed. I will do that as soon as possible.
Thank you. Your consent form and registration form will be reviewed and a prescription will be issued unless there are any concerns.

Please ensure you have paid for your starting dose of medication via the website, using the link shown when you submit this form.

If you have further questions please email me at contact@drsallynorton.com
Height and weight verified face to face?Weight verified?Height verified?BMI 27 or above (or justify below)?Consent form signedNo contraindications?
Before a final decision regarding your prescription, Dr Sally has made the following comments:
Yes - needs to purchase then prescription will be issued through SomerXYes but consent form awaitedNo - 'reason why' email sent to patient
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