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To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us. Please ensure you are filling out this form with a fast and reliable internet connection so that the images you upload come through to us. Also, please note that if this is your first order, we'll send you a link to book and speak with us following this online consultation. This is for your safety, as per updated GPhC Guidelines.

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Treatment can only be provided if your BMI is above 30. Alternatively, you must have a BMI of 27 or over and a health problem that can affect your weight such as high blood pressure, asthma or pre-diabetes.

Please select either Metric or Imperial measurements :

Metric (Centimetre and Kilograms)
Imperial (Feet and Pounds)

Allowed formats are heic, pdf, jpg, png. 10MB file size limit. PLEASE NOTE - ANY MISSED PICTURES WILL DELAY YOUR ORDER
Only .jpg, .jpeg, .png, and .gif formats are allowed.(10MB file size limit)

Height should be above 1 ft 10 inches
Only .jpg, .jpeg, .png, and .gif formats are allowed.(10MB file size limit)

  • Diabetes/Prediabetes
  • High Blood Pressure
  • High Cholesterol
  • Asthma / COPD
  • PCOS
  • Obstructive sleep apnea

The presence of any of the above conditions means you might be suitable for treatment with a lower minimum BMI of 27.



Please describe in the space provided



Please answer the following questions to understand more about your specific condition

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  • Acromegaly or any growth hormone problem
  • Chronic Malabsorption Syndrome
  • Cushings Syndrome
  • Gallbladder, Bile duct or Pancreas disease
  • Heart Failure
  • Kidney Disease
  • Liver Disease
  • Multiple Endocrine
  • Neoplasia
  • Pancreatitis
  • Personal or Family History of Thyroid Cancer

If yes please provide details of:

  • Name of medicine
  • Strength
  • Date last dose taken 

Please include:

  • Name of medicine and strength.
  • Length of treatment.
  • When you took the last dose.
  • Reason for stopping if no longer taken.

Please note: Changes to eating patterns can affect the absorption of these medications. You should continue to take these medications according to your usual routine whilst using Mounjaro or Wegovy.

Acarbose, Alogliptan, Canagliflozin, Dapagliflozin, Empagliflozin, Ertugliflozin, Fenfluramine, Glibenclamide, Gliclazide, Glimepiride, Glipizide, Insulin, Linagliptin, Orlistat, Pioglitazone, Repaglinide, Saxagliptin, Sitagliptin, Somatrogon, Tolbutamide, Vidagliptin.

This includes over the counter, prescription or recreational drugs?



Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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  • To Inform both us and your GP about any treatment-related side effects, the initiation of new medication, or changes in your medical conditions during the course of treatment.
  • To read the patient information leaflet provided with your medication before using your new treatment. If you have any questions you can contact our support team or your GP.
  • The prescribed treatment is intended exclusively for your personal use.You have provided accurate and truthful responses to all the preceding questions.
  • You acknowledge that our prescribers rely on your responses as truthful and honest to make prescribing decisions and recognise that inaccurate information may result in serious health risks.