Weight loss treatment

First name

Last name

Email

Phone no.

What is your age?

What was your sex registered at birth? (i.e your biological sex)

Are you pregnant, breastfeeding or trying to conceive (now or in the near future)?

Are you currently using oral hormonal contraception?

If using Mounjaro - I understand that I must use an additional barrier method of contraception (such as condoms) when starting treatment or for 4 weeks every time I increase my dose, as Mounjaro can reduce the effectiveness of my hormonal contraception - tick to confirm

What is your height?

What is your current weight? (It's really important you give us an accurate up-to-date measurement. You may be asked to provide evidence of your current weight)

Your BMI

What is your ethnicity? (This will help our prescribers gain a better idea about your risk in relation to your weight)

Do you have any of the following conditions?

Do you have gallbladder or bile duct issues?

Could you please provide more information about your gallbladder issues?

When did you have surgery to remove your gallbladder?

Do you have liver impairment?

Do you have any of the following liver conditions? If suitable, people with certain medical conditions may be prescribed weight loss medicines at a lower BMI than other patients.

Do you have diabetes?

Do you use any of the following medication to treat your diabetes?

People with weight-related medical conditions may be prescribed weight loss medicines at a lower BMI than other patients, if suitable. Please let us know if you have any of the following weight-related conditions

Have you ever made yourself sick (vomit) to control your shape or to lose weight?

In the last year, have you taken laxative medication in order to lose weight?

Do you worry that you have lost control over how much you eat? (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time?)

Would you say that food or image dominates your life?

Do you ever eat in secret?

Do you take any medication (from your GP, over-the-counter or herbal medication)? *Please do not include any weight loss medication you currently take - we’ll ask about this later

Do you have any allergies?

Have you had any surgery in the past 3 months?

Have you ever been diagnosed with an eating disorder (such as anorexia, binge eating disorder or bulimia) by a healthcare professional?

How much exercise do you undertake each week?

Are you CURRENTLY using any of the following (You have used a dose within the last 2 weeks)

Did you receive your last supply from ourselves, Ask Pharmacy?

How long have you been using Wegovy?

What was your weight when you started Wegovy?

Would you like to continue with Wegovy?

If you are on 0.25mg or 0.5mg of Wegovy, you must stop treatment for at least 2 weeks prior to starting Mounjaro. If you are on 1mg, 1.7mg or 2.4mg you must stop treatment for at least 4 weeks prior to starting Mounjaro.

What dose did you last use?

Would you like to remain at your current dose, increase or reduce to the next dose?

Please tell us more about why you would like to stay at your current dose/reduce your dose (such as side effects or cost)

Side effects details below

Please upload evidence of previous supply. Evidence can be: your Wegovy/Ozempic box with a pharmacy/dispensary label, a letter from your previous Pharmacy/GP or a copy of your previous prescription. Your name, the name of the medication, the date of supply and the strength should be clearly visible. Without the correct evidence your order will not be approved.

Ensure your evidence includes

• Your name
• Medication details
• Prescription Date

How long have you been using Ozempic?

What was your weight when you started Ozempic?

What dose did you last use?

We do not offer Ozempic for weight loss - would you like to switch to any of the following?

If you are on 0.25mg or 0.5mg of Ozempic, you must stop treatment for at least 2 weeks prior to starting Mounjaro. If you are on 1mg (or a higher unlicensed dose) you must stop treatment for at least 4 weeks prior to starting Mounjaro.

Did you receive your last supply from ourselves, Ask Pharmacy?

How long have you been using Mounjaro?

What was your weight when you started Mounjaro?

Would you like to continue with Mounjaro?

If you are on 2.5mg, 5mg or 7.5mg of Mounjaro, you must stop treatment for at least 2 weeks prior to starting Wegovy. If you are on 10mg, 12.5mg or 15mg of Mounjaro you must stop treatment for at least 3 weeks prior to starting Wegovy.

What dose did you last use?

Would you like to remain at your current dose, increase or reduce to the next dose?

It is recommended that only 5mg, 10mg or 15mg are used as maintenance doses in order to get the most benefit from Mounjaro. If you are using Mounjaro at 2.5mg, 7.5mg or 12.5mg, this is considered off-label(see what this means here.) *

Please tell us more about why you would like to stay at your current dose/reduce your dose (such as side effects or cost)

Side effects details below

Please upload evidence of previous supply. Evidence can be: your Mounjaro box with a pharmacy/dispensary label, a letter from your previous Pharmacy/GP or a copy of your previous prescription. Your name, the name of the medication, the date of supply and the strength should be clearly visible. Without the correct evidence your order will not be approved.

Ensure your evidence includes

• Your name
• Medication details
• Prescription Date

Did you receive your last supply from ourselves, Ask Pharmacy?

You must stop using Xenical/Orlistat before you start Wegovy/Mounjaro - Please do not take more than one weight loss medication at the same time

How long have you been using Xenical/Orlistat?

What was your weight when you started Xenical/Orlistat?

How long have you been using your weightloss medication?

What was your weight when you started your weight loss medication?

You must stop using your current weight loss medication before you start Wegovy/Mounjaro - Please do not take more than one weight loss medication at the same time

Have you ever used any of the following weight loss medications previously?

Did you obtain your last supply from Ask Pharmacy?

When did you last use the weight loss medication you mentioned?

What was your weight when you started taking the medication?

Is there any other information you feel would be useful for our clinicians to know about?

Surgery Name

Address

Postcode

Visually assess your weight

We need to visually assess your weight against your BMI and other medical history. Your photo will be used by our clinical team to assess your suitability for weight care treatment.

Make sure you:

• Stand in front of the camera to capture a face-on, standing image of your full body - ideally from the top of your head down to your feet.
• Adopt a relaxed pose with head and body facing forward, arms at your side and feet shoulder-width apart - we can accept head to hip photos but no face-only selfies please!
• Stand in front of a clear background, in full light and in focus, without any glare or obstructions.
• Wear a single layer of form-fitting clothing so we can accurately see your body shape.
• Relax - the 10 second timer lets you get into position, and you can retake your photo to get it right!

Please tick the box to confirm that you understand and agree with the statements above.

• I understand I should use one weight loss product at any one time
• I understand that the best and safest weight loss outcomes are achieved by slowly and carefully titrating the dose as per the dose escalation schedule to gain the maximum benefit from the medication. I understand that if I have a gap in treatment longer than 2 weeks, I may need to reduce my dose to avoid side effects.
• I understand that Wegovy/Mounjaro is used as an injection under the skin (subcutaneous injection). I will not inject it into a vein or muscle. The best places to give the injection are the upper arms, stomach or upper legs. I will ensure to drink plenty of fluids to avoid dehydration. I can find detailed instructions on using Wegovy/Mounjaro in the Patient Information Leaflet in the box.
• I understand that I will stop treatment and inform Ask and/or seek medical attention if I experience severe dehydration, e.g. dark urine, confusion, blood in stool or vomit, diarrhoea lasting longer than 72 hours, or being unable to keep food down without vomiting/diarrhoea.
• I understand that It is important for female patients to use reliable contraception throughout treatment with Wegovy and Mounjaro. You must stop Wegovy at least 8 weeks before trying to conceive and Mounjaro at least 4 weeks before trying to conceive. If you use oral hormonal contraception (such as the pill) while on Mounjaro, you will need to use additional barrier methods of contraception (such as condoms) for 4 weeks when starting treatment and each time you increase to a new dose. If you become pregnant while using either treatment, discontinue use immediately and consult your GP. Please tick to confirm you have read and understood this information.
• I understand that if I experience any troublesome side effects from Wegovy/Mounjaro, I can contact Ask Pharmacy, my GP, or another healthcare professional for advice. I confirm that I will read about the side effects in the Patient Information Leaflet.

Please tick the box to confirm that you understand and agree with the statements above.

• I confirm that I understand that if I place an order for Wegovy/Mounjaro after 3pm on a Thursday, Ask Pharmacy will not ship my order until Monday due to the medication being a temperature/time critical item. Unless you select the Saturday Guarantee option, which bears an extra charge.
• I confirm this treatment is for me, and I consent to this treatment. If Wegovy/Mounjaro does not help me realise my weight loss aims, I will consult my GP for further advice. I take responsibility to inform Ask Pharmacy and/or my own regular doctor of any changes in my circumstances. I agree to the Ask Pharmacy terms and conditions.
• I confirm that all the above information is truthful and accurate. I agree to inform SOP of any change to my health as soon as possible, as I understand this could impact the suitability of the medication I am being prescribed.