Patient consent form

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Full Name

Mobile Phone Number

+966

Patient Email

ID Number

Age

Weight (kg)

Height (cm)

Body Mass Index

Have you taken any action or steps regarding obesity so far?

Yes No

If your answer is Yes, what action did you take? (Select all that apply)

Following a healthy diet Regular exercise Obesity medications or treatments Bariatric (Obesity) surgery

Which medication types did you use? (Select all that apply)

Pills Injections

Your health starts with a decision! Don't hesitate to seek medical consultation today to build a safe and tailored plan for your body.

Location

Select your location

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Draw your signature in the area above using your mouse or finger.

By submitting, you acknowledge that you have read and agreed to the patient consent terms.

Health Practitioner Name

Please enter the health practitioner name.

Thank you. Your information has been received successfully.

Recommendation: Please consult your doctor about any health concerns.

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