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Complete Health Form

Please Complete Here

Birthday
Day
Month
Year
Gender At Birth
Male
Female
Have you ever taken or currently taking the following. Tick all that apply
Are you undergoing General Anaesthesia within next 6 months?
Yes
No
Do you currently have or suffered in the past with any of these conditions listed below? Tick as appropriate
Allergies
Yes
No
Pregnant or Breast Feeding
Yes
No
N/A
Current Contraception
Are You?
Perimenopausal
Menopausal
Post Menopause
Not Applicable
Are You taking HRT?
Yes
No
General State of Health
Excellent
Moderate
Poor
Alcohol Consumption
Everyday
2-3 times a week
Occasional
Never
Tabacco Consumption per day
1-5
10- 20
20+
None
Do you vape?
Yes
No
Do you use recreational drugs?
Yes
No
Your Diet
I confirm that I have answered all sections truthfully and to the best of my knowledge
Yes
I consent to treatment with WLO Ltd (SkinnyJab)
Yes
I agree and accept all company policies, terms & conditions
Yes
I agree that my name, address & DOB must be shared with our affiliated pharmacies in order to raise and dispense your prescription. We strictly DO NOT share any other information about you to these organisations
YES
I agree that all my personal information on this form is kept strictly confidential by WLO Ltd and is not shared with any third parties
Yes
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Get in Touch

Let us know how we can help you

Contact via Text/Whatsapp

+44 7803440539

SkinnyJab

WEIGHT MANAGEMENT SERVICE

ESTABLISHED 2017

+44 (0) 333 77 22 848
 

+44 (0) 7803 44 0539
 

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General Information

Opening Times

Monday- Friday

9.00am -6.00pm

Saturday

12.00pm -4.00pm

Sunday- Closed

SkinnyJab is a Registered Trademark is owned exclusively by Caroline Balazs

About Weight Management

SkinnyJab Clinic

104 Harley Street

London

W1G 7JD

CQC ID 1-452208131

​SkinnyJab Head Office

WLO (Weight Loss Online) Ltd

Director: Caroline Balazs-Pilliner

Yew Tree House,

High Street,

Wrexham

LL12 8RF

Company No: 14781213

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