Request an assessment

The physician needs the information below for a first assessment. All fields marked * are required. Your data is transmitted encrypted and stored encrypted.

Full name *

Email *

Phone

Country of residence *

Date of birth *

Height (cm)

Weight (kg)

What is your goal, and what have you tried so far?Diagnosed conditions (e.g. diabetes, thyroid, kidney, pancreas, heart, eating disorder)Current medication and supplementsKnown allergies or intolerancesPregnant, breastfeeding or planning a pregnancy?Previous use of GLP-1 or other weight-loss medicines? Which, when, and how did it go?Anything else the physician should know I confirm that I am at least 18 years old and that I am making this request for myself. I consent to the processing of the health data I provide here for the purpose of a medical assessment by the clinic, as described in the privacy notice. I can withdraw this consent at any time. (Privacy) I have read the terms of the request. (Terms of the request)

By sending, your information goes to the clinic. You receive a confirmation by email.