Weight Loss Clinical Trial Application - Panthera Clinical Trials

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Name *

Email *

Confirm Email

Phone *

Best time to call? *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Nearest Panthera Clinic *

Do you consent to the collection and processing of your personal data in accordance with the GDPR for the purposes stated in our privacy policy? *

Do you consent to the collection and processing of your personal data in accordance with the GDPR for the purposes stated in our privacy policy?

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* To proceed with your pre-screening, we need your consent to collect and process your personal data in accordance with the GDPR. Without this consent, we cannot save your initial data or determine your eligibility, which would result in an incomplete application. Please select 'Yes' to consent. For more information or assistance, contact our team.

outside Panthera your

Are you aged 18 years or over? *

Is your BMI 27 or above? *

Please use the BMI calculator below to help you answer this question, if required. If you already know your BMI, you can just answer the question above.

Unit of measurement

Height (cm)

Weight (kg)

Height

Feet

Weight (lbs)

Inch

Inches

BMI

Verdict

Have you ever been diagnosed with Type 2 diabetes? *

Was your diagnosis of Type 2 diabetes at least 6 months ago? *

Are you currently taking any injections for controlling your blood sugar or treat your diabetes e.g Insulin? *

Semaglutide (Wegovy or Ozempic)
Tirzepatide (Mounjaro)
Liraglutide (Saxenda or Victoza)

Are you currently taking any of the following injections? *

Are you currently breastfeeding or pregnant? *

Gastric bypass
Gastric band, sleeve, or balloon
Gastrectomy

Have you ever had any of the following surgeries? *

Sitagliptin
Linagliptin
Alogliptin
Vildagliptin
Saxagliptin
Orlistat

Are you currently taking any of the following medications? *

Do you have Type 1 diabetes mellitus? *

Have you had any cancers, except skin cancer, prostate cancer, or cervical cancer, in the last 5 years? *

Would you be willing to attend an appointment outside of standard weekday hours if one were available? *

Yes, early morning (before 8:00am)
Yes, evening (after 5:00pm)
Yes, weekends
Yes, any of the above
No, weekday daytime only

Have you had any organ transplants? *