Consultation form

To proceed, please agree to the following points

• I am over 18 years old and currently reside in the United Kingdom (UK).
• I will be the only user of any medication prescribed to me by The Bariatric Group.
• All answers I provide during this consultation are my own and are completely truthful.
• I have read and understood The Bariatric Group’s Privacy Policy and consent to the collection and storage of my information.

Where did you hear about us?

First Name

Surname

Email address

Contact number

Address line 1

Address line 2

Town/City

County

Postcode

Date of Birth

Gender assigned at birth

Mounjaro is not recommended for use by men or women who are trying to conceive a child.
Do you understand?

Pregnancy and Contraception Information

Please read the following important information. For your safety, its essential to follow these guidelines carefully:

• Mounjaro is not recommended for use during pregnancy or if you are trying to conceive.
• Mounjaro can reduce the effectiveness of oral contraceptives (also known as the Pill)
• If you are sexually active and on oral contraceptives, it is recommended to use non-oral contraception as well (such as condoms or a coil) while taking Mounjaro. You are advised to do this for 4 weeks after starting Mounjaro and for 4 weeks after each dose increase.

How tall are you?

What is your current weight?

What is your BMI?

Click here to calculate your BMI

How tall are you?

What is your current weight?

What is your ethnicity?

More information on ethnicityUK clinical guidelines allow for a lower BMI threshold for prescribing Mounjaro to individuals from certain ethnic groups, due to their higher risk of obesity-related health problems.

Do you have any of the following weight related conditions?

Please tick all that apply to you

Do you have any of the following conditions or do any of the following apply to you? Please select all that apply

More information on Type 1 diabetesMounjaro is not indicated in patients with type 1 diabetes, Type 2 diabetesYour risk of getting low blood sugar (hypoglycaemia) is higher if you use Mounjaro with other anti-diabetes medicines, so its use should only be supervised by your GP or diabetes nurse, Medullary thyroid cancer (MTC)Medullary thyroid cancer (MTC) is a rare type of thyroid cancer that starts in special cells called C-cells, which make a hormone called calcitonin. It can sometimes be genetic and may spread to other parts of the body., Multiple endocrine neoplasia type 2 (MEN2)Multiple Endocrine Neoplasia type 2 (MEN2) is a rare genetic condition that increases the risk of developing certain cancers, especially in the thyroid, adrenal glands, and parathyroid glands. It is caused by changes in the RET gene and is passed down in families. and GastroparesisGastroparesis is a condition where the stomach muscles don't work properly, causing food to move slowly or not at all from the stomach to the small intestine. This can lead to symptoms like nausea, vomiting, and feeling full quickly. Gastroparesis is usually diagnosed by a gastric emptying study or endoscopy.

Have you had any recent surgical / medical procedures (within the past 6 months)?

Have you ever had weight loss surgery or procedure?

Which procedure

Which year

Do you have a diagnosed mental health condition?

More information on mental health conditionPlease pay attention to depression or thoughts of self-harm. If you notice changes in your mood, behaviours, feelings, or thoughts stop the medication and contact your GP or mental health provider.

Do you, or have you ever suffered with hypoglycaemia?

Do you have any other significant health conditions or medical history, past or present?

Are you currently taking any medication, including non-prescription medicines?

Have you stopped or completed a course of medication(s) in the last 4 weeks (Including any weight loss medication)?

Have you used weight loss medication before?

If you have used weight loss medications before, did you experience any side effects from them?

Are you allergic to any medicines or other substances?

Mounjaro contains the following ingredients. Are you hypersensitive to any of these?
Please select all that apply

More information on benzyl alcoholPlease be aware that Mounjaro contains benzyl alcohol which may cause allergic reactions.

Do you consent to The Bariatric Group contacting your GP to let them know the details of any weight loss medicines we may prescribe to you?

GP Name

GP Practice Name and Address

GP Practice Email Address

Please review and confirm your understanding of the following.

• Do you understand that around 5% of people taking Mounjaro will experience side effects? The most common are nausea, diarrhoea, decreased appetite, vomiting, constipation, dyspepsia, and abdominal pain. The majority occur during dose increases and will decrease over time.
• Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication? If you experience persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting you should seek urgent medical advice.
• Do you understand that if you notice any lumps in your neck or develop a hoarse voice while using Mounjaro, you should discontinue its use and contact your doctor?
• Do you understand that if you have liver or kidney impairment you are at risk of metabolic acidosis (increase in blood acidity) whilst taking Mounjaro?
• Do you understand that Mounjaro can cause gastrointestinal effects and lead to severe dehydration?
• Do you understand that you might become hypoglycaemic using Mounjaro?
• Do you understand that weight loss medication is linked to a decrease in moodPlease pay attention to depression or thoughts of self-harm. If you notice changes in your mood, behaviours, feelings, or thoughts stop the medication and contact your GP or mental health provider.? If you experience any mental health concerns (such as depression or thoughts of self-harm) do you understand that you should discontinue the treatment and consult your doctor?
• Do you understand that if you experience any new or changing side effects (especially any uncommon or severe side effects) you must inform your GP and The Bariatric Group?

Do you understand that as you lose weight, your blood pressure may decrease. If you take medication for high blood pressure, the dosage might need to be adjusted to avoid low blood pressure? You are advised to consult with your GP to review this.

Do you understand that you must tell your anaesthetist if you are having a general anaesthetic while taking this medication, as it can slow stomach emptying.

Please review and confirm your agreement to the following terms

• I agree to read all patient information provided with any medication prescribed to me as well as any additional information shared with me during my treatment.
• I agree that I will be the sole user of any medication prescribed to me and will not allow anybody else to take them.
• I understand that injectable weight loss medications should not be used with other weight loss medications, and I confirm that I will not take any other weight loss medicines whilst I am taking the weight loss medicines prescribed to me by The Bariatric Group.
• I am aware that the weight loss medicines that may be prescribed may have limits on how they are used; and I confirm that I will follow all instructions provided to me.
• I understand there is no guarantee that any weight loss medicines prescribed will lead to weight loss; and that other lifestyle changes to my diet and activity are important factors in losing weight. I also understand that no refunds are available if I am dissatisfied with any weight loss medicines that may be prescribed to me.
• I acknowledge that the availability of the weight loss medicines is subject to change; and that The Bariatric Group cannot guarantee that any given medicine is available or will continue to be available at any time.
• I agree to inform The Bariatric Group promptly of any changes to my health or responses during this consultation, particularly if I begin taking new medications, or if there are any significant changes to my health or details that were not disclosed during this initial consultation.
• I confirm that all the information I have provided, including my medical history, is accurate, complete, and up-to-date. I understand that prescribers rely on the accuracy of my responses to make informed decisions, and that providing incorrect information may pose risks to my health, potentially leading to serious illness or side effects.
• I acknowledge that The Bariatric Group is unable to investigate issues related to Mounjaro KwikPens and cannot provide refunds or replacements. For any concerns or product complaints, I understand that I must contact the manufacturer directly by calling Lilly on 01256 315 000 or emailing ukmedinfo@lilly.com

Please use the box below to add any further information you feel is important for us to know.

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