Name {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Relationship to Patient {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Contact Telephone Number {{ 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 }
Date {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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YOUR MEDICAL HISTORY
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Any Other Health Conditions Not Mentioned above {{ 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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How Many Per Day {{ 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.
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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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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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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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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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Time on Herbal {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Weight Lost {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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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IF "YES" What Was The Outcome? If NO Please State Why: {{ 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.
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Please click on the link to read the statement before agreeing to proceed with your Weight Management Clinic Application.
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.