Name
Email Address
Age
Are you a UK resident?
Yes
No
Are you pregnant or breast feeding?
Yes
No
What is your height and weight? CM/KG
Have you been diagnosed with Type 2 diabetes?
Yes
No
Are you currently using any weight-loss medication?
Have you ever been diagnosed with any of the following? (select all that apply)
Medullary thyroid cancer
MEN2 syndrome
History of pancreatitis
Severe gastrointestinal disease
Eating disorder (past or present)
Type 1 diabetes
None of the above
I confirm the information provided is true and accurate.
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