Mounjaro - Checkout Page

Are you a male or female?
(Biological assigned gender at birth)

Male Female

What is your height?

What is your weight?

What is your blood pressure?

What is your date of birth?

Do you smoke?

Yes No

How many cigarettes do you smoke per day?

Have you had any cardiovascular(heart) problems or have you ever had a stroke?

Yes No

Can you walk 3 miles without pain in your chest?

Yes No

Do you suffer from any allergies?

Yes No

Please detail any allergies that you may have.

Are you currently taking any other medication, or have recently finished a course of medication?

Yes No

Medication name

Strength
(e.g. 100mg. If unsure, type: 'I'm not sure'.)

How many do you take a day?
(e.g. 1 tablet twice a day)

Is there a history of any disorder that has run within your family?

Yes No

Please provide more information, including as much detail as possible.

Have you ever had any major surgery?

Yes No

Please provide more information, including as much detail as possible.

Do you believe you have the mental capacity to make decisions about your own healthcare?

No Yes

You have selected you do NOT have mental capacity to make decisions about your own healthcare please provide further information, including as much details as possible.

What is your ethnicity?

Do you agree to give consent for PrescriptionDoctor.com’s prescribers and/or pharmacist to access your summary care record (SCR)?

Yes No

Have you ever used weight loss medication?

Yes No

Which weight loss medication did you last use?

Alli Mounjaro Mysimba Orlistat Xenical Ozempic Saxenda Wegovy Something Else

Please provide further information:

Are you currently using any weight loss medication?

Yes No

Which weight loss medication are you currently using /taking?

Wegovy Mounjaro Alli Mysimba Orlistat or Xenical Ozempic Saxenda Another weight loss medication

Please confirm your current dose of Wegovy or Mounjaro

Did you receive your last supply from Prescription Doctor

Yes No

Please confirm how long you have been using Wegovy/ Mounjaro.

What was your starting weight?

When did you last use your weight loss medication?

Less than 2 weeks ago More than 2 weeks ago

Please confirm if you would like to stay, increase or amend your dosage?

Stay on same dose Step up and escalate to the next dosage Step down and de-escalate to previous lower dose

Which type of weight loss treatment would you prefer?

Injections (Wegovy or Mounjaro) Tablets to reduce appetite (Mysimba) Capsules to reduce fat absorption in diet (Xenical, Alli or orlistat) I’m not sure.

Do you have any of these conditions?

High Blood Pressure (Hypertension) High cholesterol Obstructive Sleep Apnoea (OSA) No, none of these

Please confirm the condition you suffer from and further information including any medication you take

Do you have diabetes?

Yes - I have Diabetes and take medication No - I have pre-diabetes / diet controlled diabetes No

Do you take any of the following:

Sulfonylureas such as gliclazide, glimepiride Insulin GLP treatment such as Ozempic or Victoza Rybelsus Other

Has being overweight caused any other medical problems?

It might have aggravated or caused another medical problem. This could include cardiovascular disease, knee or hip osteoarthritis, asthma/chronic obstructive pulmonary disease (COPD), liver disease, mental health problems or polycystic ovary syndrome (PCOS).

Yes No

Please provide more details about these What are these problems, who diagnosed you and what treatment have you had?

Are you breastfeeding, pregnant or planning to become pregnant

Yes No

Have you ever been diagnosed with an eating disorder?

For example, bulimia or anorexia. If you think you may have an eating disorder, but have never been diagnosed, please select ‘yes’.

Yes No

What kind of eating disorder have you had? If you have had a formal diagnosis, or seen any specialists about it, please provide as much information as possible.

Do you have inflammatory bowel disease ( ulcerative colitis, Crohn’s disease etc. )?

Yes No

Do you suffer from any kidney or liver problems?

Yes No

Do you have epilepsy (seizures)?

Yes No

Do you think there could be psychological causes for your weight problem e.g. anxiety or depression?

Yes No

Please provide the condition you suffer from and further information

Do you have a medical history of any of the following listed below?

Pancreatitis
Gall Stones
Thyroid disease
Ketoacidosis
Heart Failure

Yes No

Please provide the condition you suffer from and further information including any medication you take

Have you tried to manage your weight by altering your diet and increasing physical activity?

Yes No

Have you taken any medicinal treatment that may cause weight gain?

Yes No

Is there anything else you would like to mention to our medical team which you think might be relevant?

Yes No

Please provide the condition you suffer from and further information

What is your current waist measurement?

What is your current hip measurement?

Please provide evidence of your weight on scales with your ID for our weight loss treatment program to ensure your well-being.

Select file / image

Please provide a recent full body shot or video selfie for our weight loss treatment program to ensure your well-being.

Select file / image

Important information to review

Women of childbearing potential: Wegovy, Mounjaro and all other drugs of this kind (including Ozempic and Saxenda)have the potential of causing harm to an unborn baby during pregnancy. It is vital women of childbearing age should use an adequate form of contraception whilst using these drugs. Please refer to our contraception page if you wish to review options: https://www.prescriptiondoctor.com/combined-contraceptive-pill for Mounjaro we advise you consider a non-hormonal contraception or additional barrier contraception if you are taking the pill.

Yes, I understand

Do you agree to the following?

If you plan to get pregnant, you must stop Wegovy at least 2months before trying to get pregnant, and Mounjaro at least one month.
You must let us know if your medical situation changes or you start a different medication. Just send us a message via your patient account.
Prescribed weight loss medication is only effective alongside other important lifestyle changes, e.g. Physical exercise, eating a calorie controlled diet. If I do not make these changes I may lose weight than expected ( or none) at all
I confirm this medication is for my personal use only. I have understood and answered all the questions correctly and I understand the side-effects and effectiveness of these treatment options.
I agree to read the patient leaflet before taking any medication (if prescribed).

I agree

Please upload any additional documents/information that may support your medicine request i.e. test results, etc.

Select file / image

I confirm that I have read, understood and accepted the Terms and Conditions , Privacy Policy, Delivery and Refund Policy, Cookie Information and Patient Responsibility Agreement.

I agree

Are you currently registered with a UK GP practice?

Yes No

Due to government regulations issued by the General Pharmaceutical Council, all online prescribing services now require you to confirm your GPs details so that they can be informed of your treatment. By doing so, we can make sure you're receiving the best level of care while also giving you a service that's safe, reliable and tailored to your needs.

Search for your GP by entering a postcode (yours or theirs).

Can you tell us why you are not currently registered with a GP, or why you're unsure? This consultation requires us to share this treatment with your GP.

I've only recently moved to the UK I've been removed from my practice list and not had a chance to register elsewhere Other

Do you agree that you have answered all of the above questions accurately and truthfully. You understand our prescribers will prescribe medication based on your responses, any incorrect responses or deliberate acts to misinform may be hazardous to your health. You are happy for your consultation to be reviewed by a Pharmacist Independent prescriber.

I agree

Private & confidential service

Data is kept on our systems, private and is only used by our prescribers. Your treatment sent in plain unmarked packaging.

Genuine & branded medication

Registered pharmacy in the UK, we only dispatch genuine medication. Our medical team ensure you receive the correct prescription and treatment.

Next day delivery

Prices are inclusive of free consultation. If your order is approved by 3pm you could have your medication next day UK & EU.

Please answer a few medical questions from our practitioner to prescribe your medication.

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Please answer a few medical questions from our practitioner to prescribe your medication.

Your Treatment

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