{"id":351686,"date":"2025-08-18T14:04:12","date_gmt":"2025-08-18T13:04:12","guid":{"rendered":"https:\/\/dronline.ie\/en\/?page_id=351686"},"modified":"2025-08-18T14:05:48","modified_gmt":"2025-08-18T13:05:48","slug":"weight-loss-consultation-questionnaire","status":"publish","type":"page","link":"https:\/\/dronline.ie\/en\/weight-loss-consultation-questionnaire\/","title":{"rendered":"Weight Loss Consultation Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"351686\" class=\"elementor elementor-351686\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-d12bee0 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"d12bee0\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-3475e01\" data-id=\"3475e01\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-68c8876 elementor-widget elementor-widget-heading\" data-id=\"68c8876\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Weight Loss Consultation \u2013 Patient Questionnaire<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-03bcc43 elementor-widget elementor-widget-shortcode\" data-id=\"03bcc43\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-350646\"><form id=\"wpforms-form-350646\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"350646\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/351686\" data-token=\"fd0446584b9e45df1ed8d9bc3a3fe54a\" data-token-time=\"1786448440\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-350646-field_3-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"3\"><div id=\"wpforms-350646-field_3\" class=\"wpforms-field-large wpforms-field-row\"><h2><strong>Welcome \ud83d\udc4b<\/strong><\/h2>\n<p>\ud83d\udcdd This questionnaire helps your doctor understand your health, lifestyle, and medical background so that your consultation is safe, accurate, and tailored to your needs. Please answer honestly and to the best of your ability.<\/p>\n<p>\u23f0 <strong>Please fill it out as early as possible<\/strong> to ensure the doctor as time to prepare everything you need.<\/p>\n<p>Thank you for your cooperation!<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-350646-field_39-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"39\"><div id=\"wpforms-350646-field_39\" class=\"wpforms-field-large wpforms-field-row\"><h4>1. Personal Information \ud83e\uddd1\u200d\ud83d\udcbb<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-350646-field_40-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"40\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-350646-field_40\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][40][first]\" required><label for=\"wpforms-350646-field_40\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-350646-field_40-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][40][last]\" required><label for=\"wpforms-350646-field_40-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-350646-field_41-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"41\"><label class=\"wpforms-field-label\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"email\" id=\"wpforms-350646-field_41\" class=\"wpforms-field-required wpforms-field-email-primary\" name=\"wpforms[fields][41][primary]\" spellcheck=\"false\" required><label for=\"wpforms-350646-field_41\" class=\"wpforms-field-sublabel after\">Email<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"email\" id=\"wpforms-350646-field_41-secondary\" class=\"wpforms-field-email-secondary wpforms-field-required\" data-rule-confirm=\"#wpforms-350646-field_41\" name=\"wpforms[fields][41][secondary]\" spellcheck=\"false\" required><label for=\"wpforms-350646-field_41-secondary\" class=\"wpforms-field-sublabel after\">Confirm Email<\/label><\/div><\/div><\/div><div id=\"wpforms-350646-field_43-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"43\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-350646-field_42-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_42\">Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-350646-field_42\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][42]\" aria-label=\"Phone\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-350646-field_47-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_47\">Age <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-350646-field_47\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][47]\" step=\"any\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-350646-field_38-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"38\"><div id=\"wpforms-350646-field_38\" class=\"wpforms-field-medium wpforms-field-row\"><h4>2. Body Measurements \ud83d\udccf\u2696\ufe0f<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-350646-field_31-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"31\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-350646-field_34-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-trigger\" data-field-type=\"number\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_34\">Current Weight <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-350646-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" step=\"any\" required><div class=\"wpforms-field-description\">Kilograms<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-350646-field_32-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-trigger\" data-field-type=\"number\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_32\">Height  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-350646-field_32\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][32]\" step=\"any\" required><div class=\"wpforms-field-description\">Centimetres <\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-350646-field_33-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show wpforms-calculations-field\" data-field-type=\"number\" data-field-id=\"33\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_33\">BMI<\/label><input type=\"number\" id=\"wpforms-350646-field_33\" class=\"wpforms-field-large\" name=\"wpforms[fields][33]\" step=\"any\" readonly=\"readonly\" ><div class=\"wpforms-field-description\">Body Mass Index<\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-350646-field_30-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"30\"><div id=\"wpforms-350646-field_30\" class=\"wpforms-field-medium wpforms-field-row\"><h4><strong>3. Current Weight Loss Assistance<\/strong>\u00a0\ud83d\udc8a<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-350646-field_4-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"4\"><label class=\"wpforms-field-label\">Are you currently using any medications, supplements, or treatments to help you lose weight? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_4\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_4_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][4][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_4_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_4_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][4][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_4_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_5-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"5\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_5\">If yes, please specify: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-350646-field_5\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][5]\" required><\/div><div id=\"wpforms-350646-field_6-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"6\"><div id=\"wpforms-350646-field_6\" class=\"wpforms-field-medium wpforms-field-row\"><h4><strong>4. Lifestyle Information<\/strong> \ud83c\udfc3\u200d\u2640\ufe0f\ud83e\udd57\ud83d\udca4<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-350646-field_7-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"7\"><label class=\"wpforms-field-label\">Please tick any of the following that apply to your current lifestyle: <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_7\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_7_1\" name=\"wpforms[fields][7][]\" value=\"Regular exercise (\u2265150 mins\/week)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_7_1\">Regular exercise (\u2265150 mins\/week)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_7_2\" name=\"wpforms[fields][7][]\" value=\"Balanced diet (fruit, vegetables, whole grains)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_7_2\">Balanced diet (fruit, vegetables, whole grains)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_7_4\" name=\"wpforms[fields][7][]\" value=\"High stress levels \ud83d\ude23\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_7_4\">High stress levels \ud83d\ude23<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_7_5\" name=\"wpforms[fields][7][]\" value=\"Sedentary lifestyle \ud83e\ude91\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_7_5\">Sedentary lifestyle \ud83e\ude91<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_7_6\" name=\"wpforms[fields][7][]\" value=\"Irregular eating patterns \u23f0\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_7_6\">Irregular eating patterns \u23f0<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_7_7\" name=\"wpforms[fields][7][]\" value=\"Poor sleep quality \ud83c\udf19\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_7_7\">Poor sleep quality \ud83c\udf19<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_7_8\" name=\"wpforms[fields][7][]\" value=\"Smoking \ud83d\udeac\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_7_8\">Smoking \ud83d\udeac<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_7_10\" name=\"wpforms[fields][7][]\" value=\"Alcohol consumption (&gt;7 units\/week)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_7_10\">Alcohol consumption (&gt;7 units\/week)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_7_11\" name=\"wpforms[fields][7][]\" value=\"None of the above\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_7_11\">None of the above<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_8-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"8\"><div id=\"wpforms-350646-field_8\" class=\"wpforms-field-medium wpforms-field-row\"><h4><strong>5. Medical Conditions<\/strong> \ud83e\uddec<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-350646-field_9-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"9\"><label class=\"wpforms-field-label\">Do you have any of the following? (Select all that apply) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_9\" class=\"wpforms-field-required\" data-choice-limit=\"5\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_9_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][9][]\" value=\"Thyroid condition (e.g., hypothyroidism, hyperthyroidism, thyroid cancer, family history of thyroid disease)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_9_1\">Thyroid condition (e.g., hypothyroidism, hyperthyroidism, thyroid cancer, family history of thyroid disease)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_9_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][9][]\" value=\"Pancreatic disease (e.g., pancreatitis, pancreatic insufficiency)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_9_2\">Pancreatic disease (e.g., pancreatitis, pancreatic insufficiency)<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_9_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][9][]\" value=\"Liver disease (e.g., hepatitis, cirrhosis)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_9_4\">Liver disease (e.g., hepatitis, cirrhosis)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_9_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][9][]\" value=\"Gallbladder disease (e.g., gallstones, cholecystitis)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_9_5\">Gallbladder disease (e.g., gallstones, cholecystitis)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_9_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][9][]\" value=\"Gastrointestinal condition (e.g., IBS, Crohn\u2019s disease, ulcerative colitis)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_9_6\">Gastrointestinal condition (e.g., IBS, Crohn\u2019s disease, ulcerative colitis)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_9_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][9][]\" value=\"None of the above\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_9_3\">None of the above<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_10-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"10\"><div id=\"wpforms-350646-field_10\" class=\"wpforms-field-medium wpforms-field-row\"><h4><strong>6. Medical History<\/strong> \ud83d\udcdc<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-350646-field_11-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"11\"><label class=\"wpforms-field-label\">Are you currently taking any prescribed medications? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_11\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_11_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][11][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_11_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_11_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][11][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_11_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_12-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_12\">If yes, please list: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-350646-field_12\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][12]\" required><\/div><div id=\"wpforms-350646-field_13-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"13\"><label class=\"wpforms-field-label\">Have you taken any over-the-counter products, supplements, or natural remedies in the past month? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_13\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_13_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][13][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_13_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_13_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][13][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_13_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_14-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"14\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_14\">If yes, please list: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-350646-field_14\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][14]\" required><\/div><div id=\"wpforms-350646-field_15-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"15\"><label class=\"wpforms-field-label\">Do you have any allergies (including lactose or gluten intolerance)? \ud83c\udf3e\ud83e\udd5b <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_15\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_15_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][15][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_15_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_15_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][15][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_15_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_16-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"16\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_16\">If yes, please specify: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-350646-field_16\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][16]\" required><\/div><div id=\"wpforms-350646-field_17-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"17\"><div id=\"wpforms-350646-field_17\" class=\"wpforms-field-medium wpforms-field-row\"><h4><strong>7. Continuity of Care<\/strong> \ud83e\udd1d<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-350646-field_19-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-type=\"checkbox\" data-field-id=\"19\"><label class=\"wpforms-field-label\">Do you consent to share your clinical notes with your regular GP? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_19\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_19_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][19][]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_19_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_19_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][19][]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_19_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_20-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"20\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-350646-field_21-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"21\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_21\">GP Practice Name  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-350646-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-350646-field_22-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"22\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_22\">GP Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-350646-field_22\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][22]\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-350646-field_24-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"email\" data-field-id=\"24\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-350646-field_24\">Practice or GP Healthmail Address<\/label><input type=\"email\" id=\"wpforms-350646-field_24\" class=\"wpforms-field-large\" name=\"wpforms[fields][24]\" spellcheck=\"false\" ><\/div><div id=\"wpforms-350646-field_25-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"address\" data-field-id=\"25\" style=\"display:none;\"><label class=\"wpforms-field-label\">Practice or GP Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-350646-field_25\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][25][address1]\" required><label for=\"wpforms-350646-field_25\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-350646-field_25-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][25][address2]\" ><label for=\"wpforms-350646-field_25-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-350646-field_25-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][25][city]\" required><label for=\"wpforms-350646-field_25-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-350646-field_25-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][25][state]\" required><label for=\"wpforms-350646-field_25-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-350646-field_25-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][25][postal]\" required><label for=\"wpforms-350646-field_25-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-350646-field_25-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][25][country]\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-350646-field_25-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/div><div id=\"wpforms-350646-field_26-container\" class=\"wpforms-field wpforms-field-content\" data-field-type=\"content\" data-field-id=\"26\"><div id=\"wpforms-350646-field_26\" class=\"wpforms-field-medium wpforms-field-row\"><h4><strong>8. Important Acknowledgements<\/strong> \u2705<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-350646-field_27-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"27\"><label class=\"wpforms-field-label wpforms-label-hide\">Important Acknowledgement 1 <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_27\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_27_1\" name=\"wpforms[fields][27][]\" value=\"\u2696\ufe0f I hereby confirm that I understand and agree that weight loss medication is not a substitute for a healthy diet and regular exercise.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_27_1\">\u2696\ufe0f I hereby confirm that I understand and agree that weight loss medication is not a substitute for a healthy diet and regular exercise.<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_51-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"51\"><label class=\"wpforms-field-label wpforms-label-hide\">Important Acknowledgement 2 <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_51\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_51_1\" name=\"wpforms[fields][51][]\" value=\"\u2744\ufe0f I hereby confirm that I understand and agree that some treatments must be stored in the fridge and are administered by subcutaneous injection (upper arm, thigh, or abdomen). I must read the full Patient Information Leaflet before use.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_51_1\">\u2744\ufe0f I hereby confirm that I understand and agree that some treatments must be stored in the fridge and are administered by subcutaneous injection (upper arm, thigh, or abdomen). I must read the full Patient Information Leaflet before use.<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_52-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"52\"><label class=\"wpforms-field-label wpforms-label-hide\">Important Acknowledgement 3 <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_52\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_52_1\" name=\"wpforms[fields][52][]\" value=\"\ud83d\udca7 I hereby confirm that I understand and agree that I must drink water regularly and stay hydrated during treatment.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_52_1\">\ud83d\udca7 I hereby confirm that I understand and agree that I must drink water regularly and stay hydrated during treatment.<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_53-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"53\"><label class=\"wpforms-field-label wpforms-label-hide\">Important Acknowledgement 4 <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_53\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_53_1\" name=\"wpforms[fields][53][]\" value=\"\ud83d\udcc9 I hereby confirm that I understand and agree that if I have not lost at least 5% of my initial body weight within 12 weeks, the treatment must be discontinued.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_53_1\">\ud83d\udcc9 I hereby confirm that I understand and agree that if I have not lost at least 5% of my initial body weight within 12 weeks, the treatment must be discontinued.<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_54-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"54\"><label class=\"wpforms-field-label wpforms-label-hide\">Important Acknowledgement 5 <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_54\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_54_1\" name=\"wpforms[fields][54][]\" value=\"\ud83e\ude7a I hereby confirm that I understand and agree that it is the consulting doctor who decides whether to prescribe medication. Payment for a consultation does not guarantee a treatment.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_54_1\">\ud83e\ude7a I hereby confirm that I understand and agree that it is the consulting doctor who decides whether to prescribe medication. Payment for a consultation does not guarantee a treatment.<\/label><\/li><\/ul><\/div><div id=\"wpforms-350646-field_29-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"29\"><label class=\"wpforms-field-label\">GDPR <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-350646-field_29\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-350646-field_29_1\" name=\"wpforms[fields][29][]\" value=\"I authorize the collection and processing of my data, and I am aware that it will be handled securely and in accordance with the privacy policy at dronline.ie\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-350646-field_29_1\">I authorize the collection and processing of my data, and I am aware that it will be handled securely and in accordance with the privacy policy at dronline.ie<\/label><\/li><\/ul><div class=\"wpforms-field-description\">In relation to the General Data Protection Regulation<\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"350646\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/dronline.ie\/en\/wp-json\/wp\/v2\/pages\/351686\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-350646\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/dronline.ie\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Weight Loss Consultation \u2013 Patient Questionnaire<\/p>\n","protected":false},"author":18,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-351686","page","type-page","status-publish"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.1 (Yoast SEO v28.2) - 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