Consultation Form

For new customers, please fill out the form below

Why do I need to complete a health form?

As some treatments are medications, we need to ensure you are safe & suitable to use them. Your information will NEVER be shared with any 3rd parties beyond the pharmacies and prescribers we use. Information is only ever shared with relevant professionals for your treatment.

PLEASE NOTE

We will require a form of ID to verify you are over the age of 18 and that we are providing products for the intended person. The prescribers we use may also ask for a picture or video to validate your ID and the information on your form.

If you have used the medication before & are ordering a dose which is not the starting dose, we will require proof of previous usage either of the dose your are ordering or the dose one below what you are ordering. If this information is not loaded with your health form, it may cause delays to your order.

What happens after I have done the form?

When you submit your form, you will be invited to create a free online account on our website. Your form will be screened by a prescriber and we will contact you with the outcome within 24 to 48 hours.

Online Health Form

Please fill out the following form to the best of your knowledge.

If you are making payment for your order under a different name / email address, please let us know via the notes below or via email.

Ensure your shipping address at checkout or on your invoice is correct - this address will automatically go to the courier for delivery. If the address needs amending after an order is placed or paid for but before we have shipped your order, please let us know as soon as possible to avoid an error when delivering.

If there is any information that needs updating after you submit your form, please let us know as soon as possible via email - info@ajhillaesthetics.co.uk

Your Details

First / Forename

Surname

Phone

Date of Birth

Date of birth (if date selector is not working):

Street Address

Street Address Line 2

City

County

Post Code

Please upload a form of valid ID - this can be a passport, driver's licence or birth certificate. This is only for proof of name and date of birth - you can blank out all other information

Upload File

Upload supported file (Max 15MB)

About You:

What is your height? Please specify if in feet/inches or CM:

What is your current weight? Please specify if in stones/lbs or KG

What is your target / goal weight? Please specify if in stones/lbs or KG:

What is your waist circumference? Please specify if in inches or CM:

What is your sex?

Female

Male

Please upload a picture of yourself to confirm the above information. This can be a selfie, picture of yourself in a mirror or a picture showing your weight on a set of scales. This is purely to confirm suitability for treatment.

Upload File

Upload supported file (Max 15MB)

Your Medical Background:

Please list any other medical conditions that you have been diagnosed with and details of any current health concerns/current investigations:

Are you taking any regular medications, including vitamins & supplements?

Yes

Please list any medications that you are currently taking (including prescription, over the counter, vitamins and herbal)

Are you pregnant or currently breast feeding or actively trying to become pregnant?

Yes

Have you ever had surgery?

Yes

If yes, please list the procedures & dates you had them:

Do you have any allergies?

Yes

Please list your allergies here and what reaction(s) you have:

Would you like us to inform your GP if you start treatment?

Yes

Please add your GP surgery name & postcode:

Lifestyle...

How many times per week do you currently exercise: Required

1-3

3-5

What type of exercise do you do?

How much sleep do you manage to get on an average night? Required

0-4 hours

4-6 hours

6-8 hours

Over 8 hours

How many units of alcohol do you consume on average in a week? Required

Do you smoke?

Yes

Have you tried any diets in the past?

Yes

Please list previous diets here:

Treatment Options

Which weight loss treatment option(s) are you interested in? You can choose more than one for discussion; Required

Have you tried any of these weight loss products before?

Yes

If so, please provide some details (what type of medication, dose, when you last used it, any side effects etc)

Are you requesting Starting Dose or a Higher Dose?

Starting Dose

A higher dose

What dose are you requesting?

If you are requesting a dose other than the starting dose, or have used a higher dose with another supplier, please upload proof of using the medication. This can be a picture of your prescription label on your medication's box or a copy of your order confirmation email with another supplier. Without this, your order will be delayed.

Upload File

Upload supported file (Max 15MB)

Would you like to add anti-sickness tablets to your order?

Yes

Please select anti-sickness tablets:

Cyclizine 50mg 30 tablets - £11.99

Ondansetron 4mg 28 tablets - £15.99

Ondansetron 8mg 14 tablets - £11.99

Would you like to add 28 tablets of Omeprazole (for reducing acid reflux) to your order for £10.99?

Yes

Do you know if your blood pressure is:

Normal (90/60 - 139/89)

High (140/90 or above)

Low (89/59 or below)

Packages are sent via special delivery (£4.99) and require a signature. Please select the days you can accept delivery: Required

Your item will be sent via DPD unless you request Royal Mail or live in Northern Ireland Required

DPD

Royal Mail

Northern Ireland (Royal Mail)

Do you have a promotional, loyalty or discount code to use with your order?

Important information:

Delivery Address:

Please ensure your delivery/shipping address at the payment checkout or on your invoice is the correct address - once shipped, we can no longer amend any errors with the address. Please see our Delivery Policy for further information

Licensing of the Medication:

Saxenda (liraglutide), Wegovy (semaglutide) and Mounjaro (tirzepatide) are licensed for weight loss in the UK.

Ozempic (semaglutide), Rybelsus (semaglutide) and Trulicity (dulaglutide) are not licensed for weight loss in the UK. They are licensed for Type 2 diabetes (off-label use).

Aftercare:

Please read the Patient Information Leaflet (PIL) that comes with your medication and the aftercare information available on the "My Account" area on the website. If you have any queries, please visit the Contact Us page.

Contraception:

Some of these medications may reduce the effectiveness of oral contraception. We advise you to take extra precautions if you are taking oral contraceptive medication.

Side Effects:

Like with any new medication, there is the potential for you to experience side effects. The most common side effects may include:

Nausea
Headaches
Dry Mouth
Constipation
Loose Stool
Tiredness
Stomach Cramps

Further information is available via our FAQ page, with advice & guidance on dealing with side effects via the My Account section of the website.

Adverse Effects:

Adverse effects are rare. They may include:

Palpitations / Fast Heart Rate
Pancreatitis

If you experience or feel that you may be experiencing these adverse effects, please stop using the medication & contact 111 to seek medical help. Please always read the Patient Information Leaflet that comes with your medication for more detailed information. You can also download a copy of the Patient Information Leaflet from the My Account section of the website.

Anaphylaxis:

Whilst there are no documented cases of an anaphylactic reaction to these medications, if you experience swelling of the lips/tongue/throat, difficulty breathing, tightness in the chest, a severe rash or severe itching, discontinue use immediately and call 999.

Information Sharing:

You agree to allow AJ Hill Aesthetics to share your information with relevant third parties (e.g. clinics, pharmacies, medical practitioners etc.) solely in relation to your treatment - we will never share your data unnecessarily or with any marketing companies or with any party that is not involved in your treatment.

Cancellation, Returns & Refunds:

Please read our Terms & Conditions on delivery, returns, faults and refunds. Any orders placed and screened but not yet dispensed/shipped MUST be cancelled by written communication - there will be a £25 admin fee to cover our expenses. By submitting your form, you agree to the below policies, terms & conditions:

I confirm I have read, understood & accept the above information.

Your Agreement With Us:

I understand that not following nutritional guidance, drinking alcohol or not reducing calorie intake may reduce my chance of losing weight.

I agree to take the medication as advised and directed, ensuring I will keep the medication out of reach of children & only use it for myself

I understand that once dispatched, the medication cannot be refunded as per our Terms & Conditions

I will seek urgent medical assistance if I experience anaphylactic shock

I will contact AJ Hill Aesthetics if I need help, support or guidance, or if I experience any side effects

I understand that the medication does not guarantee weight loss and results may vary

I will read the after care information available on the My Account section of the AJ Hill Aesthetics website

I agree that all the information provided is accurate, up to date & correct, and that AJ Hill have permission to contact me

Consultation Form

Online Health Form

Your Details

About You:

Your Medical Background:

Lifestyle...

Treatment Options

Important information:

Your Agreement With Us:

What are the next steps?

REVIEW
We review your form to ensure suitability to use the medication.

payment
Payment is made and the pharmacy will dispense your prescription.

DELIVERY
The pharmacy will deliver to your chosen address.

Consultation Form

Online Health Form

Your Details

About You:

Your Medical Background:

Lifestyle...

Treatment Options

Important information:

Your Agreement With Us:

What are the next steps?

REVIEW We review your form to ensure suitability to use the medication.

payment Payment is made and the pharmacy will dispense your prescription.

DELIVERY The pharmacy will deliver to your chosen address.

REVIEW
We review your form to ensure suitability to use the medication.

payment
Payment is made and the pharmacy will dispense your prescription.

DELIVERY
The pharmacy will deliver to your chosen address.