Contact Us If you’re interested in making an appointment for our weight management service, please fill out the form below and we will contact you within 2 working days. Name * First Name Last Name Date of birth * Email * Phone * (###) ### #### Do you smoke? * Yes No Height (in centimetres) * Weight (in kilograms) * Do you have any allergies to any medications? * Do you have any medical conditions? * Are you currently taking any prescribed medications? * Are you currently taking any weight loss medications? * Do you have any of the following condition? * Pre-diabetes Type 2 diabetes High blood pressure High cholesterol Underachieve thyroid Personal or family history of thyroid cancer Crohn's disease Ulcerative colitis Pancreatitis Gallstones None of these Have you ever been diagnosed with an eating disorder such as bulimia or anorexia? * Yes No Are you currently breastfeeding, pregnant or planning on getting pregnant in the next 6 months? * Yes No All initial appointments are 30 minutes in duration & priced at 145e. I understand this I understand that my appraisal may or may not necessitate a prescription weight loss medication. * I understand this I confirm I am already registered with Portmarnock GP Clinic In time we hope to be able to expand this service to those not registered with us I understand this Thank you! One of our team will contact you within 2 working days.
