Full Name*

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Full Address*

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Postcode*

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D.O.B*

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Mobile Number*

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E-mail*

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Emergency Contact Name *

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Emergency Contact Number *

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Do you have any of the medical conditions below (Tick or N/A)*

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Diabetes Type 1

Diabetes Type 2

Allergies to Injections or medications

Pregnant or Lactating

Are you taking any medications or supplements

What are your primary reasons for seeking Semiglutide peptide weight loss injections?*

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Have you previously attempted any other weight loss methods or programmes ? *

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Do you have a history of heart disease, kidney disease, or Thyroid disorder?*

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Do you have a history of eating disorders?*

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Semiglutide Peptide Injections will be administrered once a week. Are you comfortable with this frequency?*

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Please note Viviface Ltd is not responsible for weight loss results. Success may vary person to person. *

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We advise following a healthy balanced lifestyle, including regular exercise ( at least 3 times a week ) and monitoring your weight throughout the week to track progress. what changes can you make?

Semiglutide injections may have side effects. Are you aware of the potential side effects and are you willing to proceed with the injections at your own risk?*

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What is your current weight in Kgs ?*

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What is your height in CMs*

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I understand it is my responsibility to consult with my health care professional or GP before joining the weight loss program*

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Viviface Ltd would like to emphasize that the use of semaglutide is solely the responsibility of the customer. We expressly disclaim any responsibility for the improper administration or incorrect dosage of semiglutide by the customer. It is imperative for users to adhere strictly to the dosages as recommended when purchasing semiglutide. Viviface Ltd shall not be held liable for any adverse effects, complications or consequences resulting from the customers failure to follow the guidelines. Users are must consult with their own health care professionals before initiating semiglutide treatment for weight loss ensuring there are no implications on their current medications etc. By using semiglutide, the customer accepts full responsibility for their adherence to the guidelines and any consequences that arise from the misuse or incorrect administration of the medication. Viviface Ltd encourages open communication to ensure a safe and effective experience with semiglutide. Refunds are available for unopened vials, Packaging must be intact and returned by the customer. Email info@viviface.co.uk to initiate returns process within 7 days of purchase. This disclaimer is subject to change without notice, and users are encouraged to review it periodically for any updates. *

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Thank You! We will get back to you as soon as possible. To make a booking please click the link and follow the instructions. See You Soon! https://www.fresha.com/book-now/viviface-czs02oym/all-offer?pId=768424

V I V I F A C E
BEAUTY ENHANCING THERAPIES

Weight Loss Consultation Form

VIVIFACE

V I V I F A C EBEAUTY ENHANCING THERAPIES

Weight Loss Consultation Form

VIVIFACE

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BEAUTY ENHANCING THERAPIES