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InSitu Clinic Preliminary Eligibility Assessment

Thank you for your interest in InSitu.

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 the next steps.

How did you hear about InSitu?

Instagram

Facebook

Google Search

Friend or Family

Healthcare Professional

Returning Patient

Other

Personal Information

First Name

Last Name

WhatsApp Number

Mobile Number if different from WhatsApp

Email Address

Date of Birth

Gender

Location

Your Health

Current Height (cm)

Current Weight (kg)

Your calculated BMI is:

What is your primary goal?

General metabolic health

Other

Cholesterol management

Diabetes management

Weight loss

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

Are you currently pregnant or breastfeeding?

Your Treatment Journey

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.

Additional Information

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 Policy.

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 Policy.