G-Labs Weight & Wellness Declaration

Weight & Wellness

Harley Street à la Maison

The luxury of human contact is the first step of your journey to turn your challenges into triumphs. Arrange a consultation for advice, help and enquiries, whether your symptoms are acute, chronic or mild.

We offer a consultation service from the comfort of your home. Convenient and hassle free, with no need to travel to the clinic. It’s personal, affordable and easy- just click a button to schedule a date and time to be in our consultation room.

Subject to terms & conditions, your consultation fees may be applied towards products & programmes we recommend.

Declaration

First Name

Last Name

Email Address

Phone Number

Address

Date of Birth

I am the sole user of this medication & not anyone else

How much weight do you want to lose?

Do you have any chronic conditions or allergies

List any medications you are currently taking

Have you taken weight loss medication & what dosage

I have never suffered with pancreatitis or thyroid cancer.

I am not pregnant or breastfeeding

I consent that my GP may be contacted for further information if required

I agree that I may not be suitable for treatment and the practitioner’s decision is final

I consent to G-Labs® storing my medical history and data that will not be shared with any 3rd parties

I consent and subscribe to G-Labs® for occasional marketing purposes & can unsubscribe at any time

I agree to G-Labs® refund policies

All the answers I provide are truthful & accurate

Current Weight

Weight Record

Upload

Current Height

Height Record

Upload File

Proof of ID

Photo ID (Passport or Driving License)

Upload

Are you currently taking any of the following

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FOR PROFESSIONALS

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Weight & Wellness

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Harley Street à la Maison

Declaration

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