1. About you

What is your age?

18-74
75-84

What was your sex registered at birth? (i.e your biological sex)

Male
Female

What is your height?

Feet

Inches

What is your weight (kg)

(It's really important you give us an accurate up-to-date measurement. You may be asked to provide evidence of your current weight)

What is your ethnicity?

(This will help our prescribers gain a better idea about your risk in relation to your weight)

Your BMI

Do you have any of the following conditions?

Severe heart failure
Kidney impairment
Diabetic retinopathy
Pancreatitis (current or previous issue)
Gastroparesis
Ulcerative colitis or Crohn's disease
History or family history of Thyroid cancer, medullary thyroid cancer or MEN2
Any cancer, current chemotherapy or radiotherapy
None of the above

Do you have gallbladder or bile duct issues?

Yes
No

Could you please provide more information about your gallbladder issues?

I'm currently experiencing, or have previously experiences gall stones (cholestasis/cholecystitis)
I have had my Gallbladder removed
Other

Please provide more information below

and (MOUNJARO) did

Do you have liver impairment?

Yes
No

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.

Non-alcoholic fatty liver disease
Second ChoiceNon-alcoholic steatohepatitis (NASH)
I have moderate/severe Liver impairment
Other

Please provide more information below

Do you have diabetes?

I have pre-diabetic/diet controlled diabetes
Yes and I take medication for my diabetes
No

Advisory - It's important to keep us informed if your doctor starts you on any medication relating to your pre-diabetes/diet controlled diabetes, as this may impact your treatment.

Do you use any of the following medication to treat your diabetes?

Insulin
Sulphonylureas (such as gliclazide, glimepiride, glipizide)
Ozempic
Other

Please list all your medication below:

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

Please provide more information below

Have you ever made yourself sick (vomit) to control your shape or to lose weight?

Yes
No

In the last year, have you taken laxative medication in order to lose weight?

Yes
No

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?)

Yes
No

Would you say that food or image dominates your life?

Food and image, yes
Food, yes
Image, yes
No, neither

Do you ever eat in secret?

Yes
No

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

Yes
No

Please provide more information below

Do you have any allergies?

Yes
No

Please provide more information below:

Have you had any surgery in the past 3 months?

Yes
No

Please provide more information below:

Have you ever been diagnosed with an eating disorder (such as anorexia, binge eating disorder or bulimia) by a healthcare professional?

Yes
No

Please provide more information below:

How much exercise do you undertake each week?

Less than 60 minutes
60-120 minutes
More than 120 minutes

In order to get the best weight loss results with Wegovy, you do need to use it in conjunction with regular exercise of more than 60 minutes per week.

3. Your Treatment

Are you CURRENTLY using any of the following (You have used a dose within the last 2 weeks)

(WEGOVY)Did you receive your last supply from ourselves, Chemist2Customer?

Yes
No, I received it from another Pharmacy/Clinic

(WEGOVY) Would you like to continue with Wegovy?

Yes. I'm happy with Wegovy
No, I would like to switch to Mounjaro

If you are on 0.25mg of Wegovy, you must stop treatment for at least 2 weeks prior to starting Mounjaro.

If you are on 1mg, 1.7mg, or 2.4mg, you must stop treatment for at least 4 weeks prior to starting Mounjaro.

(WEGOVY) What dose did you last use?

(WEGOVY) Would you like to remain at your current dose, increase or reduce to the next dose?

Yes, I'd like to increase the next dose
I'm happy with my current dose
I would like to reduce to the previous lower dose

(WEGOVY) Please tell us more about why you would like to stay at your current dose/reduce your dose (such as side effects or cost)

Achieving weight aims
Cost
Side effects
Other

(WEGOVY)Please provide more information below:

(NOT C2C WEGOVY) How long have you been using Wegovy?

(NOT C2C WEGOVY) What was your weight when you started Wegovy? (kg)

(NOT C2C WEGOVY) Would you like to continue with Wegovy?

Yes, I'm happy with Wegovy
No, I would like to switch to Mounjaro

(NOT C2C Wegovy) What dose did you last use?

(NOT C2C Wegovy) Would you like to remain at your current dose, increase or reduce to the next dose?

Yes, I'd like to increase to the next dose
I'm happy with my current dose
I would like to reduce to the previous dose

Please upload evidence of previous supply. Evidence can be: your Mounjaro box with a pharmacy/dispensary label, a letter from your previous Pharmacy/GP, or a copy of your previous prescription. Your name, the name of the medication, the date of supply, and the strength should be clearly visible. Without the correct evidence, your order will not be approved.

Field #119 (copy)

Click or drag a file to this area to upload.

Ensure your evidence includes:

Your name
Medication details
Prescription Date

(NOT C2C Wegovy) Please tell us more about why you would like to stay at your current dose/reduce your dose (such as side effects or cost)

Achieving weight aims
Cost
Side effects
Other

(NOT C2C Wegovy) Please provide more information below

If you are on 0.25mg of Wegovy, you must stop treatment for at least 2 weeks prior to starting Mounjaro.

If you are on 0.25mg or 0.5mg of Wegovy, you must stop treatment for at least 2 weeks prior to starting Mounjaro. If you are on 1mg, 1.7mg, or 2.4mg, you must stop treatment for at least 4 weeks prior to starting Mounjaro.

(OZEMPIC) How long have you been using Ozempic? Write below

(OZEMPIC) What was your weight when you started Ozempic? (kg)

(OZEMPIC) What dose did you last use?

(OZEMPIC) We do not offer Ozempic for weight loss - would you like to switch to any of the following?

Wegovy (this is equivalent to Ozempic)
Mounjaro

If you are on 0.25mg of Wegovy, you must stop treatment for at least 2 weeks prior to starting Mounjaro.

If you are on 0.25mg or 0.5mg of Ozempic, you must stop treatment for at least 2 weeks prior to starting Mounjaro. If you are on 1mg (or a higher unlicensed dose) you must stop treatment for at least 4 weeks prior to starting Mounjaro.

(OZEMPIC) Would you like to remain at your current dose, increase or reduce to the next dose?

Yes, I'd like to increase to the next dose
I'm happy with with my current dose
I would like to reduce to the previous lower dose

(OZEMPIC) Please tell us more about why you would like to stay at your current dose/reduce your dose (such as side effects or cost)

Achieving weight aims
Cost
Side effects
Other

(OZEMPIC) Please provide more information below

(MOUNJARO) Did you receive your last supply from ourselves, Chemist2Customer?

Yes
No, I received it from another Pharmacy/Clinic

(MOUNJARO) Would you like to continue with Mounjaro?

Yes, I'm happy with Mounjaro
No, I would like to switch to Wegovy

(MOUNJARO) What dose did you last use?

(MOUNJARO) Would you like to remain at your current dose, increase or reduce to the next dose?

Yes, I'd like to increase the next dose
I'm happy with my current dose
I would like to reduce the previous lower dose

It is recommended that only 5mg, 10mg or 15mg are used as maintenance doses in order to get the most benefit from Mounjaro. If you are using Mounjaro at 2.5mg, 7.5mg or 12.5mg, this is considered off-label (see what this means here.)

I agree to the off-label use of Mounjaro and REMAIN on my CURRENT dose
I would like to INCREASE to the next dose
I would like to DECREASE to the previous maintenance dose

(MOUNJARO) Please tell us more about why you would like to stay at your current dose/reduce your dose (such as side effects or cost)

Achieving weight aims
Cost
Side effects
Other

(MOUNJARO) Please provide more information below:

(NOT C2C MOUNJ) How long have you been using Mounjaro?

(NOT C2C MOUNJ) What was your weight when you started Mounjaro? (kg)

(NOT C2C MOUNJ) Would you like to continue with Mounjaro?

Yes, I'm happy with Mounjaro
No, I would like to switch to Wegovy

(NOT C2C MOUNJ) What dose did you last use?

(NOT C2C MOUNJ) Would you like to remain at your current dose, increase or reduce to the next dose?

Yes, I'd like to increase to the next dose
I'm happy with my current dose
I would like to reduce the previous lower dose

Please upload evidence of previous supply. Evidence can be: your Mounjaro box with a pharmacy/dispensary label, a letter from your previous Pharmacy/GP, or a copy of your previous prescription. Your name, the name of the medication, the date of supply, and the strength should be clearly visible. Without the correct evidence, your order will not be approved.

I do not have evidence of previous supply

I do not have evidence of a previous supply

Click or drag a file to this area to upload.

Ensure your evidence includes:

Your name
Medication details
Prescription Date

I agree to the off-label use of Mounjaro and REMAIL on my CURRENT dose
I would like to INCREASE to the next maintenance dose
I would like to DECREASE to the previous maintenance dose.

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1. About you

What is your height?

2. Your Medical History

3. Your Treatment

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