Consultation - Mentor Pharmacy

These questions are designed to help us understand how you will use the medication we may prescribe for you. Should you require assistance completing this form then please contact a member of our Customer Care team.

Please Note: If this is your first time taking this medication, you will only be allowed to order the initial strength for Mounjaro (2.5mg) and Wegovy (0.25mg). Following the initial dose, subsequent orders will be increased in strength using a stepwise approach.

Do you acknowledge and affirm your agreement with the following?

1. You are between the ages of 18yrs to 75yrs and live in the United Kingdom.

2. You affirm that you are completing this consultation on your own behalf and are providing information to the best of your knowledge and ability.

3. You confirm that this treatment is solely for your own use and commit to utilising only one weight loss treatment concurrently.

4. You agree to read the Patient Information Leaflet supplied with the medication (if prescribed) and confirm that you are aware of the possible side effects of the medication.

5. You commit to fully disclosing any medical conditions, significant illnesses, surgical procedures, and current prescription medications.

6. You agree to your GP being informed of this purchase (if prescribed), and grant permission to our prescribers gaining access to your medical history, only when absolutely necessary.

7. You acknowledge and accept our Terms of Use, Terms of Sale, and Cancellation and Refund Policy, and you confirm that you have reviewed and understood our Privacy Policy.

Acne

Asthma

Contraceptives

Eczema and Dermatitis

Erectile Dysfunction

Hay Fever

Menopause

Pain Relief

Urinary Tract Infection (UTI)

Ear Wax Removal

Private Blood Tests

Weight Management

Assessment for Weight Loss

1 Acknowledgement

Do you acknowledge and affirm your agreement with the following?

2 About You and Your Health

With which ethnic group do you primarily identify?

Are you currently pregnant, trying to conceive, or breastfeeding?

What is your weight?

What is your height?

Have you been diagnosed with diabetes?

Do any of the following apply to you?

Do any of the following apply to you?

Do you suffer from any other medical conditions?

Is this a Critical Condition ?

Please describe below

Are you currently taking any prescribed medication, over the counter medication or recreational drugs?

Please describe below

Are you allergic to any medicines or other substances?

Please describe below

Do you have a history of eating disorders or mental health conditions related to food or weight?

Please describe below

Have you ever used any weight loss medication?

Please describe below

Would you like to remain on your current dose or increase?

If applicable we require evidence of your current dosage.

Have you ever experienced any side effects when using weight loss medication?

Please explain below

What is your target weight?

How often do you exercise for a minimum of 20 minutes or more?

Do you consume alcohol?

Do you smoke?

Assessment Progress

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