Q1: What are your main reasons for wanting to lose weight? Improve my overall health
Address specific health concerns
Feel stronger, more energised, and rested
Improve my mobility and reduce pain
Feel more confident
Preparing for surgery
I have a different reason
We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q2: What’s your weight loss goal? Losing up to 1 stone (approx. 6.5 kg)
Losing 1 to 3.5 stone (approx. 6.5 to 22 kg)
Losing more than 3.5 stone (over 22 kg)
Not sure, I just want to lose some weight
We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q3: How many different weight loss programmes have you tried in the past? None, this is my first time trying
1 to 5
6 to 10
More than I can remember
We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q4: What's your height?

Q5: What's your weight?

Q6: Do you have any of the following?

We ask this because healthy weight ranges vary for different ethnic backgrounds.

• Prediabetes
• Type 2 diabetes
• High blood pressure
• High cholesterol
• Heart or blood vessel disease (including previous heart attack)
• Previous stroke
• Osteoarthritis
• Obstructive sleep apnoea
• Metabolic dysfunction-associated steatotic liver disease (MASLD). Previously known as non-alcoholic fatty liver disease.
• Polycystic ovary syndrome (PCOS)

Q7: What is your ethnicity? Asian or Asian British
Black, African, Caribbean or Black British
Middle Eastern
Mixed or multiple ethnicities (including Asian, Black, or Middle Eastern backgrounds)
White (including White British, White Irish, and other White backgrounds)
Other ethnic group
Prefer not to say

Q8: Are you aged 18 to 74 years old?

Q9: Have you ever experienced an allergic reaction to any of the following medications: Wegovy/Ozempic (semaglutide), Mounjaro (tirzepatide), or Saxenda/Victoza (liraglutide)?

Q10: Are you currently pregnant, breastfeeding, or planning a pregnancy?

GLP-1 medications (such as Mounjaro and Wegovy) should not be used during pregnancy or while breastfeeding. If you are planning a pregnancy, you must stop using Wegovy at least 2 months before trying to conceive, and stop using Mounjaro at least 1 month before.

Q11: Do you have, or have you ever had, any of the following conditions?

It’s important you tell us about your medical history to help us provide safe and effective treatment recommendations.

• Pancreatitis
• Liver cirrhosis or a liver transplant
• Any form of cancer that is currently being treated by a specialist
• Active retinopathy
• Heart failure with shortness of breath at rest
• Chronic kidney disease with reduced function (eGFR less than 30ml/min – you can find this information on your kidney function blood test)
• Severe gastrointestinal disease, including inflammatory bowel disease (eg ulcerative colitis or Crohn's disease), or gastroparesis (delayed stomach emptying)
• Treatment or rehabilitation for excessive alcohol use
• Chronic malabsorption syndrome (problems absorbing nutrients)
• An endocrine (hormone) disorder, such as overactive thyroid disease awaiting radioactive iodine or surgery, acromegaly, Addison’s disease, Cushing’s syndrome, congenital adrenal hyperplasia, or a growth hormone disorder
• Any cognitive or memory impairment, such as dementia, that may impact the ability to make decisions

Q12: Do you have any of the following gallbladder issues?

• Gallstones that have not been removed
• Blocked bile flow (cholelithiasis)
• Gallbladder infection (cholecystitis)
• Gallbladder surgery in the past 12 months

Q.13: Have you had bariatric weight-loss surgery or a gastric band procedure (either placement or removal) within the past 12 months? This also includes any of the following

• Sleeve gastrectomy (gastric sleeve)
• Gastric bypass (Roux-en-Y)
• Gastric balloon
• Endoscopic sleeve gastroplasty
• Biliopancreatic diversion or duodenal bypass

Q14: Have you ever had an eating disorder, for example, anorexia or bulimia nervosa?

If you think you may have an eating disorder, but have never been diagnosed, please choose ‘yes’. It’s important for your health to answer this honestly.

Q15: Have you been diagnosed with type 1 diabetes?

If yes, it’s important to let us know here.This treatment can affect insulin requirement and blood sugar regulation, so GLP-1 medication should only be prescribed to people with type 1 diabetes under the supervision of a diabetes team.

Q16: If you have type 2 diabetes, are you using insulin?

If yes, it’s important to let us know here.This treatment can affect insulin requirement and blood sugar regulation, so GLP-1 medication should only be prescribed to people with type 2 diabetes using insulin under the supervision of a diabetes team.

Q17: If you have type 2 diabetes, are you taking any oral or injectable medication (other than metformin and insulin) to manage your blood sugar?

Q18: Do you have a personal or family history of medullary thyroid cancer, thyroid cancer, or multiple endocrine neoplasia type 2 (MEN2) syndrome?

Q19: Are you currently taking any of the following medications?

• Amiodarone
• Carbamazepine
• Ciclosporin
• Clozapine
• Digoxin
• Fenfluramine
• Lithium
• Mycophenolate mofetil
• Oral methotrexate
• Phenobarbital
• Phenytoin
• Somatrogon
• Tacrolimus
• Theophylline
• Warfarin

Q20: Are you currently a smoker?

Q21: Are you taking any medications to treat your thyroid?

Q22: Have you taken injectable weight loss medication in the last 6 months?

Q23: To make sure we’re providing safe and effective treatment for you, we need to make sure you’re on the right dose. Do you understand that you will be asked to provide evidence of a prescription with an alternative provider if the following applies to you?

This is your first order of injectable weight-loss drugs from Pharmazon Express and you do not order the starter dose.
Your last order with Pharmazon Express was more than 6 months ago and you have been receiving medication from another provider.

Q24: Injectable weight-loss treatments such as Mounjaro and Wegovy may increase your risk of developing pancreatitis, gallbladder problems, and gallstones. If you experience severe abdominal pain (especially if it moves to your back), vomiting, or worsening symptoms, please seek urgent medical attention by calling 999 or visiting A&E.

Do you agree?

Q25: If you are sexually active, note that Mounjaro may reduce the effectiveness of the oral contraceptive pill. This means you’ll need to use other forms of contraception (such as condoms or an IUD/implant) while taking Mounjaro to prevent unplanned pregnancy.

Do you agree?

Q26: Severe diarrhoea (lasting over 24 hours) or vomiting (within 3 hours of taking your oral contraceptive pill) may impact its effectiveness. You may need a repeat dose of your oral contraceptive pill and should call 111 for medical advice if this occurs to avoid unplanned pregnancy.

Do you agree?

Q27: Injectable weight-loss treatments such as Mounjaro and Wegovy should not be used with other weight-loss treatments.

Do you agree?

Q28: Injectable weight-loss treatments may be associated with changes in mood. If you experience any new symptoms, such as low mood, suicidal thoughts, thoughts of self-harm, or other mental health concerns, you should pause treatment and consult your doctor.

Do you agree?

Q29: Do you agree to the following?

• The information I have provided is true and accurate to the best of my knowledge.
• The information I have provided will be used by the prescribers to decide whether it is appropriate to supply medication.
• I understand that failure to give accurate information may result in a refusal to supply medication, or the supply of medication that is not suitable.

Q30: Do you agree to the following?

• The treatment is solely for my own use.
• I will read the patient information leaflet supplied with the medication.
• I will contact Pharmazon Express and inform my GP if I experience any side effects from treatment, begin any new medication, or if my medical conditions change during the course of treatment.
• I agree to Pharmazon Express notifying my GP that I am taking GLP-1 weight-loss medication and to allow my GP to share information with Pharmazon Express if they have any concerns.
• I give my permission for Pharmazon Express to request further medical information from my GP if necessary.
• I agree to the collection, processing, and storage of my personal and sensitive health data for the purpose of assessing my prescription request.
• I agree to have my data shared with relevant healthcare professionals as necessary for my care.
• I understand that I can withdraw my agreements at any time and that I will be provided with instructions on how to do so.

I agree to the Terms and Conditions and I confirm that I am over 18. You must agree to continue.

 Important: Consultation Required Before Order Fulfilment Please note that your order will only be fulfilled after a consultation with our prescriber. Once your order is placed, we will send you a link to book an appointment with the prescriber. Please complete the consultation to confirm your eligibility for the treatment.