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Sunway Obesity Clinic
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Contact Us

About
Our Doctors
Sunway Obesity Clinic
Sunway Physio & Rehab
Center Of Excellence
Specialities
Resources
- Health Packages
- Blog
- Vlogs
- News
- Testimonials
- Stories
Contact Us

Appointment

Eligibility Form

First Name *

Last Name *

Age *

Gender *

Mobile Number *

Email Address *

Body Measurements

Height (cm) *

Weight (kg) *

Safety Screening

Please answer all questions carefully and honestly.

Are you currently pregnant or planning to become pregnant? *YesNo

Are you currently breastfeeding? *YesNo

Have you ever been diagnosed with pancreatitis? *YesNo

Do you have a personal or family history of medullary thyroid carcinoma (MTC)? *YesNo

Have you been diagnosed with Multiple Endocrine Neoplasia type 2 (MEN2)? *YesNo

Do you have Type 2 Diabetes? *YesNo

Do you have any thyroid disorders? *YesNo

Do you have Polycystic Ovary Syndrome (PCOS)? *YesNo

Do you have high blood pressure or high cholesterol? *YesNo

Do you have any kidney or liver disease? *YesNo

Do you have any gallbladder issues or chronic gastrointestinal disorders? *YesNo

Do you have any physical condition or disability that prevents you from exercising? *YesNo

Have you had any recent surgeries or hospitalisations in the last 6 months? *YesNo

Do you have any history of eating disorders (e.g. anorexia, bulimia)? *YesNo

Do you have a history of depression, anxiety, or mental health conditions? *YesNo

Medications & Lifestyle

Help us understand your current health routine.

Are you currently taking any prescription medications? *YesNo

Are you on diabetes medications (including insulin)? *YesNo

Have you used weight loss medication or injections before? *YesNo

Any known drug allergies? *

Physical Activity Level *Mostly sedentaryLight (1–2×/week)Moderate (3–4×/week)Active (5+×/week)

Diet Type *VegetarianVeganEggetarianPescatarianNon-VegetarianMixed

Do you currently smoke? *YesOccasionallyNo

Do you consume alcohol? *RegularlyOccasionallyNo

Average sleep duration per night *Less than 5 hrs5–6 hrs7–8 hrsMore than 8 hrs

Primary goal *Weight lossBlood sugar controlBothOverall health improvement

How did you hear about us?

Anything else you'd like us to know? *

Upload a Full Body Photo (Optional)

You can upload now or send it later via WhatsApp.

Why do we ask for a photo?

Clinical progress tracking – your doctor compares photos at enrolment and every 3 months.

Patient safety – helps identify underweight or vulnerable patients.

Strictly confidential – visible only to you and your doctor.

✔ Correct

Full body, standing, clear view

✖ Not accepted

Half body / cropped

✖ Not accepted

Face / selfie only

Tap to upload your full body photo *

Drag and Drop (or) Choose Files

Patient Responsibility & Compliance Agreement

Please read each statement carefully. By ticking the boxes below, you confirm your understanding and agreement to all items.

I confirm all information I have provided is accurate, complete, and truthful to the best of my knowledge.
I am at least 18 years of age, of sound mind and judgement, and am permitted by the laws of India to receive this treatment for my personal use.
I understand that a licensed physician at Sunway Medical Centre will make all clinical decisions regarding my treatment, and a valid prescription is required before any medication is dispensed.
I agree to undergo all required baseline medical investigations before starting treatment, and repeat screenings every 6 months or as directed by my doctor.
I understand the potential benefits and risks of this prescription treatment, and will immediately contact a doctor if I experience any adverse effects or side effects.
I agree that the medication dispensed is solely for my personal use and will not be shared, sold, or stockpiled beyond an adequate personal supply.
I agree to attend all required follow-up consultations and monthly review appointments, and understand that failure to attend may result in suspension of the Slimify programme.
I consent to Sunway Medical Centre securely storing and processing my personal and medical data, including my body photograph, for the purpose of clinical care — visible only to me and my treating doctor.
I understand that the Slimify programme supports, not replaces, my relationship with my regular healthcare providers. I agree to inform any other treating practitioners of all medications I am taking.

I have read and understood all 9 statements above, and I confirm that all information I have provided is accurate. I agree to comply with all Slimify programme requirements including follow-ups, investigations, and medical guidance.

I voluntarily consent to the Slimify clinically supervised weight loss programme and agree to the Patient Responsibility Agreement , Terms & Conditions, and Privacy Policy of Sunway Medical Centre.

Medical Disclaimer: This service is intended for medically supervised weight management. Treatment decisions are made by a licensed physician based on individual clinical assessment. Patients may be required to undergo diagnostic testing before and during treatment. Outcomes vary between individuals. This tool does not replace a medical consultation.

Full Name (Electronic Signature) *

Date *

Your case requires further clinical review.

Based on your responses, your case needs a personalised assessment by one of our physicians before a decision can be made. Your details have been sent to our team and they will be in touch shortly.

What happens next:

Your details have been sent to our team via WhatsApp
We will call or WhatsApp you within 24 hours
We'll arrange your online consultation booking
Consultation fee collected via Razorpay
Doctor assessment + baseline investigations
Treatment begins upon prescription issuance

What happens next:

This automated eligibility check is based solely on your self-reported information and is a preliminary screening tool only. It is not a medical diagnosis and does not replace a clinical assessment by a qualified physician. Final eligibility is determined exclusively by a Sunway Medical Centre physician. All information is held strictly confidential.