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Consent

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Full Name

Are you over 18?

Yes No

Date of Birth

Date

Month

Year

NULL

Have you had Bariatric Surgery with us?

Yes No

Which treatment have you had?

Which year did you have this procedure?

GP Name

Surgery Address

What is your current BMI? Enter Value (Do not know? Calculate here)

Mounjaro is indicated for weight loss and weight management in adults aged 18 and over.

Mounjaro is authorised for adult patients with a BMI of 30kg/m² or more (obesity), as well as those with a BMI between 27-30kg/m² (overweight) who also have weight-related health problems such as prediabetes, high blood pressure, high cholesterol, or heart problems.

The medicine is to be used together with a reduced-calorie diet and increased physical activity.

Please fill in details.

Do you have any of the following conditions?

Diabetes type 2 Pre-Diabetes High blood pressure High cholesterol High levels of lipids in the blood Obstructive sleep apnea Cardiovascular disease None applicable

- No

Are you, or could you be, pregnant

Yes No

No No

Are you currently breastfeeding?

Yes No

No No

Do you understand that this medication should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child?

Yes No

Do you have a history of pancreatitis (inflammation of the pancreas)?

Yes No

No No

Have you ever been diagnosed with gastroparesis?

Yes No

No No

Have you had any recent surgical / medical procedures, including surgery for the purpose of weight loss?

Yes No

NULL op1

Please provide further information

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Your medicines

Are you currently taking any medication, including nonprescription medicines, or have you recently (within the last 4 weeks) finished a course of medication? (Including any weight loss medication)

Yes No

- op1

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Are you allergic to any medicines or other substances?

Yes No

- op1

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If you have used weight loss treatments before, have you experienced any side effects from them?

Yes No

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Please provide further information

Do you have type 1 diabetes?

Yes No

No No

Please provide further information

Do you have type 2 diabetes?

Yes No

- No

Please provide further information

Are you currently taking insulin?

Yes No

NULL No

Please provide further information

Are you aware if you are on insulin you are at a higher risk of hypoglycaemia.

Yes No

op2

Information leaflet

Are you on any other tablets or injections to control your blood sugar, other than metformin?

Yes No

NULL No

Do you confirm that you understand this medication can sometimes worsen pre-existing diabetic eye disease? If you notice any changes in your vision while taking the medication, please report them urgently to your GP or eye specialist.

I confirm

NULL No

Are you or have you suffered with hypoglycaemia, for example -- fainting, dizzy spells, migraines, shaking, low blood sugar levels.

Yes No

No No

Are you aware that you might become hypoglycaemic using Mounjaro?

Yes No

op2

Information leaflet

Are you aware this medication can cause gastrointestinal effects and lead to severe dehydration.

Yes No

op2

Information leaflet

Have you ever had an eating disorder?

Yes No

No No

Do you have depression, anxiety or any other mental health condition?

Yes No

NULL op1

Please provide further information

Are you aware that mounjaro contains Benzyl alcohol and this may cause allergic reactions.

Yes No

op2

Information leaflet

Are you aware that if you have liver or kidney impairment you are at risk of metabolic acidosis (increase in blood acidity).

Yes No

op2

Information leaflet

Please fill in details.

More information

Are you hypersensitive to any of the following --

Tirzepatide
Sodium phosphate
Dibasic heptahydrate
Sodium chloride
Concentrated hydrochloric acid, and sodium hydroxide (for pH adjustment)
Glycerol
Phenol
Benzyl Alcohol
Water for injections

Yes No

No No

Have you experienced an allergic reaction to any weight loss medications such as - tirzepatide (Mounjaro), Semaglutide (Wegovy) or Liraglutide (Saxenda)?

Yes No

No No

Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome?

Yes No

No No

Do you understand that you may need to show proof of prescription from another provider if

This is your first order with The Bariatric Group and you have not ordered the starter dose
Your last order with The Bariatric Group was over 8 weeks ago, and you are requesting a higher dose

Yes No

*Mounjaro may affect how well oral contraceptives (sometimes known as ‘the Pill’) work in obese or overweight females.

Obese or overweight female patients using oral contraceptives should consider also using a barrier method of contraception (e.g., a condom) or switching to a non-oral contraceptive method for 4 weeks after starting Mounjaro and for 4 weeks after each dose increase.

Do you understand?

Yes No

Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice?

Yes No

Do you understand that injectable weight loss medications should not be used with other weight loss medications?

Yes No

Do you understand that if you notice any lumps in your neck or develop a hoarse voice while using this medication, you should discontinue its use and contact your doctor?

Yes No

Weight loss, including treatments involving injections, can sometimes lead to a decrease in mood. If you experience this, such as feelings of depression, thoughts of self-harm, or other mental health concerns, do you understand that you should discontinue the treatment and consult your doctor?

Yes No

Please fill in details.

Do you agree to the following terms?

You will read the patient information leaflet provided with your medication.
You will inform your GP and notify The Bariatric Group if you experience any uncommon or severe side effects from the treatment, start new medication, or if there are any changes in your medical conditions during treatment.
The treatment is intended solely for your personal use.
You confirm that you have answered all the questions above honestly and accurately. You understand that our prescribers rely on the accuracy of your responses to make informed prescribing decisions, and that providing incorrect information may pose risks to your health.

Yes No

Please read the following and confirm by ticking each box that you understand and agree.

I have read and understand and agree to all of the information provided to me about the weight loss medicines that may be prescribed. I confirm that all of the information that I have provided about myself and my medical history is accurate; complete and up-to-date. I am aware that providing incorrect information may lead to serious illness and side effects. I confirm that I will notify The Bariatric Group immediately if any of my answers to the questions that I have answered changes (especially if I start taking any other medications). 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 confirm that I will only use the weight loss medicines that may be prescribed to me for my own personal use; and will not allow anybody else to take them. I understand that weight loss medicines that may be prescribed can lead to side effects; and I will tell The Bariatric Group or my GP straight away if I experience any side effects. I understand that you will contact my GP to let them know the details of any weight loss medicines that you prescribe to me so that they have a complete record of my treatment. I confirm that I will not take any other weight loss medicines whilst I am taking the weight loss medicines prescribed to me through The Bariatric Group. I understand that there is no guarantee that weight loss medicines that may be prescribed to me will cause me to lose weight; and that other lifestyle changes to my diet and activity are important factors in losing weight. I 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.

- No

BMI	Gastric Band	Gastric Sleeve & Bypass	Gastric Balloon
27 +			Available
30 +	Available		Available
35 +	Available	Available	Available

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