Your Consultation Form

Online Health Form

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

Your Details

What is your sex?
Upload File

Your Medical Background:

Do you currently have or have a history of the following conditions (please tick all that apply):
Have you ever been diagnosed with:
Are you pregnant or currently breast feeding?
Are you actively trying to get pregnant?
Have you ever had surgery under general anesthetic?
Do you have any allergies?

A bit about you...

How many times per week do you currently exercise:
How much sleep do you manage to get on an average night?
How many units of alcohol do you consume on average in a week? (This tool may help get a more accurate level )
Do you smoke?

Your ID

Treatment Options

Which weight loss treatment option(s) are you interested in?
For the Weekly Injection or Daily Tablet, these items are NOT yet licensed for weight loss and it would be prescribed to you off-label (for another purpose other than its current license)
Have you tried any of these weight loss products before?
Would you like to add 30 anti-sickness tablets to your order for £9.99?
Your package is sent via special next day delivery for £4.99 & needs to be signed for. What days can you accept deliver?

For your information:

Please read the below information thoroughly & carefully. ​Only click agree if you fully understand the information. If you are unsure, please contact us via email.

How the medication works:

The medications we provide all work in very similar ways. The major difference is that the weekly jab is a slow-release version of the daily jab & tablet.


Produced by Novo Nordisk, the medication mimics a natural hormone already found in your body (GLP-1). It works in three key ways to reduce your appetite.


  1. It blocks a key hunger hormone telling your brain that you are hungry, whilst also helping to reduce leptin resistance (a hormone which can affect your metabolism & weight). This also helps stop the weight from coming straight back on when you stop the jab.

  2. It slows down the gastric emptying process, meaning that your body takes longer to process food and it is fuller for longer. This means your body does not need as much intake as normal as it works off the food it has.

  3. The medication helps to speed up your metabolism and increase fat burning by reducing glucagon & reducing insulin resistance. This promotes normal blood glucose levels, the liver metabolism of glucose and helps adipose tissue burn fat in a safe and controlled method without causing a sugar-crash. This avoids the urges for quick-fix sugary foods.


This all helps to reduce the risk of the so-called "starvation mode".

How to administer the medication:

We will send you an aftercare email which will have the full instructions on how to take the medication. The medication also comes with the manufacturer's Patient Information Leaflet which explains how to take the medication.

For the injections, we provide a demo video so that you can pause, rewind & re-watch the video in your own time at your own speed.

All of the literature and videos are also available on our online members area.

Licensing of the medication:

The daily injection is licensed for weight loss the UK & EU under the brand name Saxenda.

The weekly injection and the daily tablet are NOT yet licensed for weight loss in the UK & EU. Novo Nordisk (the manufacturer) has been approved for a weight loss license for the medication in the UK & EU but the new brand of that licensed weight loss medication (Wegovy) is not yet available within the UK. It has been approved for weight loss in the USA and is available there under the brand name Wegovy.

It is safe & legal to prescribe a medication for a purpose other than it's current license - this is called off-label prescribing. You must be aware and fully informed of this, plus all the information regarding the medication (how it works, side effects etc) before being prescribed a medication off-label.

Side Effects:

Everyone is different. You may not experience any side effects, you may experience one side effect or several side effects.


The most common side effects associated with this medication are:



Dry Mouth


Loose Stool


Stomach Cramps

We send aftercare literature to advice you on how to deal with these side effects should you experience them. Please do not hesitate to contact us if you need any support on dealing with side effects. We are more than happy to advise you.

Adverse Effects:

Adverse effects are rare but they are something you should be aware of.

Adverse effects may include:

Palpitations / Fast Heart Rate


If you experience or feel that you may be experiencing these adverse effects, please stop using the medication & contact 111. When you are safe to do so, please contact us.


There have been no documented cases of an anaphylactic reaction to Liraglutide or Semaglutide but as this is a new medication being introduced to your body, we want to make you aware of the possible signs of anaphylaxis.

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.

For further information, see

Your Agreement With Us:

I understand that drinking alcohol during the programme may effect my weight loss results.
I agree to take the medication as advised and directed by the pharmacy
I agree to keep the weight loss medication out of reach of young children at all times and that the medication will solely be used by myself.
I understand & agree that no refunds can be issued once the medication has been dispatched
I agree that I will seek urgent medical attention (999) in the highly unlikely event of an anaphylactic shock
I agree that I will contact my provider (AJ Hill Aesthetics) if I experience difficulty with using or any side effects when using the medication or if I require any additonal support with my weight loss journey.
I understand that the medication does not guarantee weight loss for everyone; my weight loss may be less or more than the average
I agree to read the after care and literature whilst following the recommendations of AJ Hill Aesthetics to the best of my ability.

What are the next steps?

We send your form to the pharmacy for review.

If suitable, we send you an invoice.
Once paid, the pharmacy will prescribe.

The pharmacy will deliver to your chosen address.