Weight Loss Clinic Information Form

Please complete the form. Our Primary Care Assistant will call you to discuss the next steps and organise your appointment with either Dr Fiona MacLean or Dr Jayne Davies.

Your name

Your contact number

Date of Birth

Your email address

Are you a registered patient of Aspiring Medical Centre

Yes

Tell us a bit about your weight concerns including what you have tried in the past and what your aims are.

Do you have any other health concerns?

Are you on any medications at the moment? Please list them if you are

What is your current weight in Kgs

What is your height in Cms

Do you have any allergies? Please list them if you do

Do you drink alcohol?

Yes

If yes how much per week

Do you smoke/vape

Yes

Monday - Friday

Weekends and Public Holidays

After Hours

Email

Aspiring Medical Centre

Book an appointment

Repeat prescriptions

Request a GP call-back