Health Form

Please fill out the health form below & click submit when you finish

Online Health Form

Please fill out the following form to the best of your knowledge. Please note, 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. If there is any information that needs updating after you submit your form, please let us know as soon as possible via email. Please ensure the correct shipping address is submitted at the online checkout or that the shipping address on your invoice is correct - the shipping address submitted at checkout is what will automatically go to the courier for delivery. If the address needs amending after an order is placed or paid for, please let us know as soon as possible to avoid an error when delivering. Please read our Delivery Policy for further information.

Your Details

First / Forename

Surname:

Phone

Date of Birth

Date of Birth (if box above does not work for you)

Street Address

Street Address Line 2

City

County

Post Code

What is your height?

What is your current weight?

What is your goal weight?

What is your waist circumference?

What is your sex?

Female

Male

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

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?

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?

Yes

Are you actively trying to get pregnant?

Yes

Have you ever had surgery under general anesthetic?

Yes

Please list your previous procedures & dates of when you had them:

Do you have any allergies?

Yes

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

A bit about you...

How many times per week do you currently exercise:

1-3

3-5

What type of exercise do you do?

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

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? (This tool may help get a more accurate level https://www.drinkaware.co.uk/understand-your-drinking/unit-calculator )

Do you smoke?

Yes

Have you tried any diets in the past? If so, what ones?

Treatment Options

Which weight loss treatment option(s) are you interested in?

Ozempic (Weekly Semaglutide Injection)

Wegovy (Weekly Semaglutide Injection)

Mounjaro (Weekly Tirzepatide Injection)

Rybelsus (Daily Semaglutide Tablets)

Trulicity (Weekly Dulaglutide Injection)

Saxenda (Daily Liraglutide Injection)

What dose are you requesting?

For Ozempic, Trulicity, Rybelsus & Victoza, 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)

I understand

I am not opting for Ozempic, Trulicity, Rybelsus or Victoza

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)

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

Would you like to add 30 anti-sickness tablets to your order for £9.99?

Yes

Do you have a code to use for your order?

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.

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.
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.
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:

Please create a FREE account via the My Account page on our website. All of the after care, support articles and videos are available via the My Account section.

Licensing of the medication:

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

Ozempic (semaglutide), Rybelsus (semaglutide) and Trulicity (dulaglutide) are NOT yet licensed for weight loss in the UK & EU. They are currently licensed for Type 2 diabetes.

A medication can be prescribed 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:

Nausea
Headaches
Dry Mouth
Constipation
Loose Stool
Tiredness
Stomach Cramps

Further information is available via our FAQ page and the aftercare page in the My Account section of the website. 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
Pancreatitis

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.

Anaphylaxis:

There have been no documented cases of an anaphylactic reaction to these medications 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.

Cancellation, Delivery, Returns & Refunds:

Please read our policies on delivery, returns and refunds. Any orders placed and screened but not yet dispensed/shipped MUST be cancelled by written communication - there will be a £10 admin fee to cover our expenses.

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

Your Agreement With Us:

I understand that drinking alcohol during the programme may effect my weight loss results.

Yes

I agree to take the medication as advised and directed.

Yes

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.

Yes

I understand & agree that no refunds can be issued once the medication has been dispatched as per our Terms & Conditions.

Yes

I agree that I will seek urgent medical attention (999) in the highly unlikely event of an anaphylactic shock

Yes

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.

Yes

I understand that the medication does not guarantee weight loss for everyone; my weight loss may be less or more than the average

Yes

I agree to access and read the after care information available on the My Account section of the AJ Hill Aesthetics website. This is free to access.

Yes

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

aj hill

Health Form

Online Health Form

Your Details

Your Medical Background:

A bit about you...

Treatment Options

For your information:

Your Agreement With Us:

What are the next steps?

REVIEW
We send your form to the pharmacy for review.

payment
If suitable, we send you an invoice.
Alternatively, you can pay on the next page.

DELIVERY
The pharmacy will deliver to your chosen address.

Health Form

Online Health Form

Your Details

Your Medical Background:

A bit about you...

Treatment Options

For your information:

Your Agreement With Us:

What are the next steps?

REVIEW We send your form to the pharmacy for review.

payment If suitable, we send you an invoice. Alternatively, you can pay on the next page.

DELIVERY The pharmacy will deliver to your chosen address.

REVIEW
We send your form to the pharmacy for review.

payment
If suitable, we send you an invoice.
Alternatively, you can pay on the next page.

DELIVERY
The pharmacy will deliver to your chosen address.