PATIENT REGISTRATION FOR MEDICATION

Date

DayMonthYear
Please complete the following registration form which is required for professional clinic records regarding issuing of prescriptions.

Apologies for any repetition, but I need to ensure I have the current information from you.

Thank you.
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Email*
Mobile number (required for delivery of prescription)*
Please check number is correct
Have we met face to face or via an online consultation? If online only I will need photographic evidence of your height and weight for compliance purposes.*

Face to face +/- onlineOnline only
VERIFIED HEIGHT AND WEIGHT MEASUREMENT

Some less reputable providers are prescribing weight loss medication or advice online without evidence that the patient is overweight. This is not safe and is against the ethical code of medical practice. In addition, it does not comply with the Care Quality Commission regulations. I am passionate about ensuring that I am providing a properly conducted service, in keeping with my responsibilities as a medical doctor.

If you wish to register with me for weight loss services, therefore, I need to verify this information.

Please provide photographic evidence of your height and weight. If you can wear tight-ish clothing I can also see and assess your body shape which will provide me with further insight on your health risks.

Please provide:

Without this information I am unable to provide you with a prescription for weight loss medication, sorry!
Please upload evidence of height*

Cancelof
Please upload evidence of weight*

Cancelof
Weight in kg*
Please check your answer is correct
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 current medication and dose*
Please record any allergies or enter none*
You have already provided me with your medical history. Please note any new changes or record none*
Please record any diseases that may run in your family that you have not already informed me about 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.
Have you signed the consent form for medication?

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 Wegovy via the website, using the link shown when you submit this form.

If you have further questions please email me at contact@drsallynorton.com
Able to issue prescription?

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:
Suitable for prescription?

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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