Preliminary Eligibility Assessment

This confidential form helps our clinical team determine whether you may be suitable for our physician-led weight management services. Completing this form does not guarantee treatment or a prescription. If you are eligible to proceed, a member of our team will contact you to discuss next steps.

How did you hear about InSitu? *

First Name *

Last Name *

WhatsApp Number *

Mobile Number (if different from WhatsApp)

Email Address *

Date of Birth *

Gender *

Location *

Current Height (cm) *

Current Weight (kg) *

Your calculated BMI is: —

What is your primary goal? *

Have you ever used a weight-management medication (such as Mounjaro®, Zepbound®, Wegovy®, Ozempic®, Tirzepatide, or Semaglutide)? *

Yes No

Which medication? *

Are you currently pregnant or breastfeeding? *

Yes No

What best describes you today? *

I am ready to begin treatment as soon as possible. I would like to learn more before deciding. I am comparing treatment options. I am seeking a second opinion.

Is there anything you would like our clinical team to know before contacting you?

Consent *

I confirm that the information I have provided is true and accurate to the best of my knowledge. I understand that completing this form is a preliminary screening only and does not guarantee eligibility for treatment or the prescription of medication. I consent to InSitu collecting and processing my personal information for the purpose of assessing my enquiry and providing healthcare services in accordance with its Privacy Notice. I consent to being contacted by telephone, WhatsApp, SMS and email regarding my enquiry and clinical assessment. I have read and agree to the Terms of Service and Privacy Notice.

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Preliminary Eligibility Assessment

Assessment received