Name
*
First Name
Last Name
Email address:
What is your postal address?
Which weight loss medicine would you like to purchase?
Are you purchasing this medicine for yourself?
Are you aged between 18-74?
Are you breast feeding, pregnant or planning to become pregnant?
Women of reproductive age who are thinking about using Wegovy should use contraception. If planning to become pregnant, discontinue Wegovy at least two months in advance.
What is your target weight?
Weight loss medication may be prescribed if your BMI is over 27 and you have a weight related medical condition. Please let us know if you have any of the following conditions:
Do you smoke?
Do you drink alcohol?
Have you ever been prescribed or currently taking weight loss medication or undergoing a low energy diet plan?
We will only provide Wegovy or Mounjaro if you have titrated your dose correctly. You MUST start from 0.25mg or 2.5mg and work your way up. This is to reduce unwanted side effects and risk of serious illness. You will be asked for evidence if you order a higher strength.
Do you or have you ever suffered from an eating disorder such as Bulimia Nervosa or Anorexia?
Do you have any of the following conditions?
Do you take any of the following medication?
- Anticoagulants to thin the blood such as; Warfarin, Rivaroxaban
- Amiodarone
- Thyroid Medication
- Vitamin A, D, E or K supplements
- Ciclosporin
- Anti-retroviral medications such as tenofovir, efavirenz, abacavir or emtricitabine
- Acarbose
- Epilepsy Medication
- Oral Contraceptives
- Diabetes or polycystic ovaries medication or insulin
Do you exercise 4-5 times a week for 30 minutes?
Exercise can include activities such as walking, running, cycling, and swimming.
How many calories do you believe you consume daily?
Weight loss treatments are only effective with a low-calorie diet and exercise plan.
Do you have any kidney or liver impairment?
Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?
Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?
Are you allergic to any medicines or other substances e.g. peanuts or soya?
We need to let your GP know about your treatment to ensure you get the best level of care possible. Please provide us your GP details.
I agree that: Stock for Mounjaro, Wegovy and Saxenda is limited and intermittent. We cannot guarantee the ongoing supply and cost of any strengths. Supply is subject to availability.
FAO MOUNJARO PATIENTS ONLY: I understand that I will need needles, swabs and a sharps bin to use Mounjaro.
These items can be purchased from the online shop and instore.
I agree to the following: For Mounjaro, Wegovy and Saxenda Patients
- Mounjaro and Wegovy is administered once a week whereas Saxenda is administered once daily at any time.
- Mounjaro, Wegovy and Saxenda are for subcutaneous use only. It must not be administered in any other way. It should be injected in the stomach area (abdomen), upper leg (thigh) or upper arm. I have watched the video on how to use and administer Saxenda.
- I will not share my pen with anyone else as it may not be suitable for them and can cause infections.
- I will store my pens in a fridge (2°C to 8°C) to maintain the cold chain. The pen currently in use can be kept out of the fridge for up to one month under 30°C.
- Mounjaro, Wegovy and Saxenda can cause dehydration. To avoid dehydration, I will drink at least 2 litres of water a day.
- Mounjaro, Wegovy and Saxenda are used for weight loss in addition to diet and exercise in adults aged 18 and above.
- I will stop using Mounjaro, Wegovy or Saxenda if I fail to lose 5% of my body weight whilst taking 12 weeks of full dose of (15mg), Mounjaro, (2.4mg) Wegovy or (3mg) Saxenda.
- I have read the patient information leaflet before purchasing Saxenda (see below).
- I have read the patient information leaflet before purchasing Wegovy (see below).
- I have read the patient information leaflet before purchasing Mounjaro (see below).
- Our clinician may call from time to time to ensure you are taking your medication as prescribed and to provide more advice and guidance.
Do you agree to the following?
- You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
- You have answered the questions honestly and accurately and the treatment is solely for your personal use.
- You will read and understand the patient information leaflet supplied with your medication.
- You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
- You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
- You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy (featured below).
