Consultation - Mentor Pharmacy

2 Your Medical History

Please help our clinicians gain a full and accurate medical history to ensure we are providing the best and safest care for you

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 surgeries in the last 3 months?

Have you ever been diagnosed with an eating disorder such as anorexia/bulimia/binge-eating disorder?

How much exercise do you undertake typically on a weekly basis?

Less than 60 minutes

Between 60 and 120 minutes

More than 120 minutes

3 Your Treatment

Which medication are you looking to order?

Are you CURRENTLY using any weight loss treatments (You have used a dose within the last 3 weeks)

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

Please provide details of your current GP. To ensure the best level of care, you are required to provide these details before we can review your treatment. We will notify your GP if a supply is made. Your order may be delayed if the information is not correct.

4 The Agreement and Consent

Please take the time to carefully read the Agreement and Consent statements during our online consultation process. Understanding these statements is essential for your safety and for ensuring that you are fully informed about the treatment you will receive. The Agreement and Consent sections outline important information about the risks, benefits, and responsibilities associated with your medication. By reading and agreeing to these terms, you help us ensure that you are aware of and comfortable with the treatment plan. Your informed consent is crucial for providing you with the best possible care. Thank you for your cooperation and trust in our services. Do you understand that you must use an additional barrier method of contraception when starting Mounjaro or for 4 weeks when increasing my dose, as Mounjaro can reduce the effectiveness of my hormonal contraception (if this applies to you). This treatment, should be taken in conjunction with a well balanced, calorie controlled/nutritional diet. It should contain 30% of calories from fat and be rich in fruit and vegetables. It is advised to keep a good level of hydration, to avoid suffering from dehydration. Are you aware that Mounjaro can cause the following side effects: Possible thyroid tumours, including cancer. Tell your health care professional if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rats and mice, Mounjaro and medicines that work like Mounjaro caused thyroid tumours, including thyroid cancer. It is not known if Mounjaro will cause thyroid tumours or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people. Do not use Mounjaro if you or any of your family have ever had MTC, or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Do you understand that acute pancreatitis is an uncommon side effect of Mounjaro treatment? Patients should look out for the signs of pancreatitis whilst using Mounjaro. These include severe, persistent abdominal pain that radiates to the back, tenderness when touching the abdomen, rapid heartbeat, fever, nausea and vomiting. If you suspect pancreatitis, stop using Mounjaro and see your GP. Are you aware that this medicine should not be used during pregnancy, as it is not known if it may affect your unborn child? It is recommended to use contraception while using this medicine, switch from oral to non-oral contraceptives for the first four weeks when Mounjaro is initiated. If you wish to become pregnant, you should stop using this medicine at least two months in advance. If you become or are pregnant, think you may be pregnant or are planning to have a baby when using this medicine, talk to your doctor straight away, as your treatment will need to be stopped. You should not use this medicine. If you are breast-feeding, it is unknown if it passes into breast milk use with caution. Are you aware that Mounjaro must be administered by using the following method: Inject your dose of Mounjaro under the skin (subcutaneous injection) in your stomach area (abdomen), upper leg (thigh), or upper arm, as instructed by your health care provider. Do not inject into a vein or muscle. Never share your Mounjaro pen or needles with another person. You may give an infection to them, or get an infection from them. Mounjaro is a ONCE weekly injection You will store Mounjaro in a refrigerator (2°C to 8°C) on receipt of delivery. If you do not do this, Pharmacy Online cannot be held responsible for the medication not functioning as intended. Once you start using the pen, you can keep the pen for 1 month when stored at a temperature below 30°C or in a refrigerator. Do you understand that if you place an order for Mounjaro after 3.30pm on a Friday, Heba Online Pharmacy will not ship your order until the following Monday due to the medication being a temperature/time critical item. This applies even if you choose the 'next day delivery' option on the checkout page. This may change around public holidays so please look out for your delivery confirmation email.

I agree to the terms of using Mounjaro

Are you aware you should not use Wegovy if any of the following applies: You or any of your family have a history of MTC You have MEN 2. This is a disease where people have tumours in more than one gland in their body Diabetic retinopathy (Eye condition that can cause vision loss and blindness in people who have diabetes) You are allergic to Semaglutide or any of the ingredients in Wegovy. Symptoms of a serious allergic reaction may include: swelling of your face, lips, tongue, or throat, fainting or feeling dizzy, very rapid heartbeat, problems breathing or swallowing, and severe rash or itching This medicine should not be used during pregnancy, as it is not known if it may affect your unborn child. Therefore, it is recommended to use contraception while using this medicine. If you wish to become pregnant, you should stop using this medicine at least two months in advance. If you become or are pregnant, think you may be pregnant or are planning to have a baby when using this medicine, talk to your doctor straight away, as your treatment will need to be stopped. You should not use this medicine if you are breast-feeding, as it is unknown if it passes into breast milk.

I agree to terms of using Wegovy

Do you understand that we are required to inform your GP practice about any treatment prescribed to you?

We are required by the General Pharmaceutical Council to notify your GP practice of any weight loss medications prescribed to you.

Do you agree to the following?

We are required by our regulator to visually assess our patients for suitability for these medicines. You will receive a MS Teams invite once your order has been placed from one of our expert pharmacists for a 1-1 consultation. This consultation will be based on the answers you have provided within the form and will be used to assess your suitability. This should take between 10-15 minutes and can be booked at your convenience.

Acne

Asthma

Contraceptives

Eczema and Dermatitis

Erectile Dysfunction

Hay Fever

Menopause

Shingles

Urinary Tract Infection (UTI)

Ear Wax Removal

Private Blood Tests

Assessment for Weight Loss

Weight Loss

1 About You

How old are you?

What was your sex assigned to you at birth?

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

Are you currently using oral hormonal contraception?

What is your height?

What is your weight?

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 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.

What type of liver impairment do you have?

Do you have diabetes?

Do you use any of the following medication for your diabetes?

What other medication do you take for your diabetes?

Do you have any gallbladder or bile duct issues?

Could you please provide more information about your gallbladder issues?

Please provide further information below

When did you have your surgery to remove your gallbladder?

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

What have you tried in the past to lose weight?

Please provide further information below

What challenges have you faced with exercise or trying to be more active?

What challenges have you faced when changing your eating habits?

Please provide further information below

What challenges have you faced when trying to stay on track with your weight loss?

Please provide further information below

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?)

2 Your Medical History

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

Please provide further details below

Do you have any allergies?

Please provide further information below

Have you had any surgeries in the last 3 months?

Please provide further information below

Have you ever been diagnosed with an eating disorder such as anorexia/bulimia/binge-eating disorder?

Please provide further information below

How much exercise do you undertake typically on a weekly basis?

3 Your Treatment

Which medication are you looking to order?

Are you CURRENTLY using any weight loss treatments (You have used a dose within the last 3 weeks)

Did you receive your last supply from us - Heba Online Pharmacy?

How long have you been using this medication for?

What strength of Wegovy did you last use?

What strength of Mounjaro did you last use?

What was your weight when you started on weight loss treatment?

Please provide a clear image of your previous supply - this should include your name, the date the supply was made, the medication supplied and the strength supplied to you, for example, a picture of the pharmacy label on the medication box or an invoice supplied by your last provider.

Would you like to continue with this medication?

Would you like to remain on the same dose, increase or your dose or reduce your dose?

Please provide further details as to why you would like to stay on the same dose

Please provide further details as to why you would like to reduce your dose

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

Please provide further details below

Please provide details of your current GP. To ensure the best level of care, you are required to provide these details before we can review your treatment. We will notify your GP if a supply is made. Your order may be delayed if the information is not correct.

4 The Agreement and Consent

Do you understand that we are required to inform your GP practice about any treatment prescribed to you?

Do you agree to the following?

Assessment Progress

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