Please completed the form for the Strathearn Health & Beauty Weight Management Programme.                                                                    * are mandatory fields.

Please select any of the following which apply to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Title                                    Forename                                                                    Surname {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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IN CASE OF EMERGENCY

Please provide contact details for us to contact someone in the event of emergencies.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ID Verification (for Patients Wishing to Use the Remote Clinic Services Only)

It is a legal requirement that Strathearn Health & Beauty verify the identity of ALL NEW patients wishing to join the Medical Weight Management Programme Remote Services (Telephone/Video Consultations).  We would therefore ask that all NEW patients wishing to register for the remote services, upload a form of Government Issued Photo ID using the button below.  Acceptable forms of ID are (but not limited to): Drivers Licence, Passport, Disability Blue Badge, International Travel Card etc…

 

Patients who do not have any form of official Photo ID are unfortunately not eligible to register for Remote Services online, however, these patients can still register for Remote Clinic Services (telephone/Video Call) by attending our clinic for registration and the initial consultation.

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Clicking "Upload" will give you the option to either take a photo using your phone/laptop/tablet camera of your photo ID or to upload an existing image from your device's library.

If you DO NOT have a valid form of photo ID please tick the box below.  By ticking this box you consent to attend the clinic for an initial Face to Face consultation with the clinic doctor.  After this first consultation you will have the option to either continue with Face to Face consultations or to use the remote consultations (telephone/video call) for future appointments.

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but I am happy to continue with my registration and will attend a face to face consultation  where I can register for Remote Services for future consultations.

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GP Details

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Address of your GP Surgery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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DECLARATION

Strathearn Health & Beauty advises all patients to share details of their Treatment at our clinic with the patient's own GP and/or healthcare providers. ALL patients will be given a GPL1 (Letter to GP) which will be located in the Patient Portal.  This can be emailed, printed or posted to the Patient's GP by the patient at any time. 

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YOUR MEDICAL HISTORY

Please tick if you suffer from or have ever suffered from any of the following conditions.

 

Please tick if you suffer from or have suffered from any of the following conditions: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you taking any or have taken any of the following or any other medication/herbal supplements (i.e St John's Wort)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you smoke? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you drink alcohol? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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One unit is the equivalent of:   1/2 pint of normal strength beer, lager or cider.1 small glass of wine. One single (25ml) measure of spirits or 1 small glass (50ml) of Sherry or Port. 

Have you ever used any of the following medications/Herbal to lose weight? If YES, please indicate how successful they were.

Diethylpropion/Tenuate Dospan {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phentermine/Ionamin/Duromine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Xenical/Orlistat {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bulking Agents {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Herbal Preparations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ABOUT YOUR WEIGHT, EATING, EXERCISE AND APPETITE SUPPRESSANTS.

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Weight measured in Stones and lbs or Kilos {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please indicate your reasons for wanting to lose weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Which of these factors have caused you to put on weight: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please complete the following questions regarding your eating and exercise patterns: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
ALWAYSUSUALLYSELDOMNEVER
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Have You Consulted With Your GP About Your Weight? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have You Consulted With Your GP About Taking Appetite Suppressants? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you researched Appetite Suppressant Medication (UK Specials)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you been on any of the following Weight Loss Programmes? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If "YES" please indicate how successful they were:

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In order to lose weight, I must follow a calorie controlled plan and understand that any appetite suppressants prescibed to me by the clinic doctor is only to help curb appetite and is not for obesity.
I agree to the above statement: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please click on the link to read the statement before agreeing to proceed with your Weight Management Clinic Application.

PATIENT CONSENT FOR WEIGHT MANAGEMENT TREATMENT

Consent to Proceed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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CONFIDENTIALITY

All patient information including pictures held by Strathearn Health & Beauty Ltd is private and confidential and compliant with GDPR regulations.  On occasion, regulatory bodies may inspect your file.  Further information on access to medical and treatment records is available on the department of health website: www.nhs.uk.

COMPLAINTS

If you wish to make a complaint, you can do so by calling the clinic on 0141 333 1900, sending an email to info@strathearnhealthandbeauty.co.uk and as from 1st April 2017, you can also contact Healthcare Improvement Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9EB, or by calling 0131 623 430.  Please see our website for full details of our complaints procedure at: Strathearn Complaints Procedures.  We are a member of ICO.

Please completed the form for the Strathearn Health & Beauty Weight Management Programme.                                                                    * are mandatory fields.

Please select any of the following which apply to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Title                                    Forename                                                                    Surname {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Date Of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Sex/Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Mobile Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Occupation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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IN CASE OF EMERGENCY

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Relationship to Patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Contact Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

ID Verification (for Patients Wishing to Use the Remote Clinic Services Only)

It is a legal requirement that Strathearn Health & Beauty verify the identity of ALL NEW patients wishing to join the Medical Weight Management Programme Remote Services (Telephone/Video Consultations).  We would therefore ask that all NEW patients wishing to register for the remote services, upload a form of Government Issued Photo ID using the button below.  Acceptable forms of ID are (but not limited to): Drivers Licence, Passport, Disability Blue Badge, International Travel Card etc…

 

Patients who do not have any form of official Photo ID are unfortunately not eligible to register for Remote Services online, however, these patients can still register for Remote Clinic Services (telephone/Video Call) by attending our clinic for registration and the initial consultation.

Submit Photo ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you DO NOT have a valid form of photo ID please tick the box below.  By ticking this box you consent to attend the clinic for an initial Face to Face consultation with the clinic doctor.  After this first consultation you will have the option to either continue with Face to Face consultations or to use the remote consultations (telephone/video call) for future appointments.

I DO NOT HAVE PHOTO ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How did you hear about us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Other Please Specify {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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GP Details

Your GP Name or Surgery Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address of your GP Surgery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Telephone No {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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DECLARATION

I understand the importance of sharing my treatment information wth my own GP {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I DO NOT wish to share this information with my GP nor do I give consent for my GP to be contacted by the clinic. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient's Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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YOUR MEDICAL HISTORY

Please tick if you suffer from or have suffered from any of the following conditions: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any Other Health Conditions Not Mentioned above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you taking any or have taken any of the following or any other medication/herbal supplements (i.e St John's Wort)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If YES, please give a description of the medication/supplement and what you use it for. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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when did you last take a dose? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you smoke? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How Many Per Day {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you drink alcohol? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Units Per Week {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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One unit is the equivalent of:   1/2 pint of normal strength beer, lager or cider.1 small glass of wine. One single (25ml) measure of spirits or 1 small glass (50ml) of Sherry or Port. 

Have you ever used any of the following medications/Herbal to lose weight? If YES, please indicate how successful they were.

Diethylpropion/Tenuate Dospan {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Time on Medication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phentermine/Ionamin/Duromine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Time on Medication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Xenical/Orlistat {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Time on Medication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bulking Agents {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Time on Bulking Agent {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Herbal Preparations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Time on Herbal {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Others? Please specify {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Time on Others {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ABOUT YOUR WEIGHT, EATING, EXERCISE AND APPETITE SUPPRESSANTS.

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What is your current Weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight measured in Stones and lbs or Kilos {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please indicate your reasons for wanting to lose weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If "Other" Please Specify Untitled {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Which of these factors have caused you to put on weight: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please complete the following questions regarding your eating and exercise patterns: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How much weight to you want to lose? (14lbs in 1 Stone) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How long do you think it will take to achieve the weight loss? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have You Consulted With Your GP About Your Weight? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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IF "YES" What Was The Outcome? If NO Please State Why: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have You Consulted With Your GP About Taking Appetite Suppressants? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you researched Appetite Suppressant Medication (UK Specials)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you been on any of the following Weight Loss Programmes? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If "YES" please indicate how successful they were:

Time on Programme {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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In order to lose weight, I must follow a calorie controlled plan and understand that any appetite suppressants prescibed to me by the clinic doctor is only to help curb appetite and is not for obesity.
I agree to the above statement: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Please click on the link to read the statement before agreeing to proceed with your Weight Management Clinic Application.

PATIENT CONSENT FOR WEIGHT MANAGEMENT TREATMENT

Consent to Proceed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

CONFIDENTIALITY

All patient information including pictures held by Strathearn Health & Beauty Ltd is private and confidential and compliant with GDPR regulations.  On occasion, regulatory bodies may inspect your file.  Further information on access to medical and treatment records is available on the department of health website: www.nhs.uk.

COMPLAINTS

If you wish to make a complaint, you can do so by calling the clinic on 0141 333 1900, sending an email to info@strathearnhealthandbeauty.co.uk and as from 1st April 2017, you can also contact Healthcare Improvement Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9EB, or by calling 0131 623 430.  Please see our website for full details of our complaints procedure at: Strathearn Complaints Procedures.  We are a member of ICO.