Mounjaro Weight Loss Injection

What is your height? (Feet and Inches)

What is your weight? (Kg)

What is your date of birth? (DD/MM/YY)

Have you been told you have dyslipidaemia? (High Cholesterol)

If ‘yes’ please provide details:

Have you been told you suffer from sleep apnoea?

If ‘yes’ please provide details:

Are you taking medication for blood pressure?

If ‘yes’ please provide details:

Do you have diabetes?

If ‘yes’ please provide details:

Do you have any allergies?

If ‘yes’ please provide details:

Do you have any eating disorders, or have you had any in the past?

If ‘yes’ please provide details:

Are you currently dependent on chronic opiates or opiate agonists (e.g. methadone), or are you going through an acute withdrawal (cold turkey)?

If ‘yes’ please provide details:

Have you been told by your doctor you have an intolerance to lactose?

If ‘yes’ please provide details:

Do you have liver or kidney problems?

If ‘yes’ please provide details:

Do you have a condition that causes seizures, or do you have a history of seizures?

If ‘yes’ please provide details:

Do you have any heart or circulation problems?

If ‘yes’ please provide details:

Do you or have you ever had a condition affecting the circulation of blood in the brain? (example mini-stroke, stroke, brain tumour?

If ‘yes’ please provide details:

Do you frequently use cocaine or other stimulants?

If ‘yes’ please provide details:

Are you a heavy drinker?

If ‘yes’ please provide details:

Are you currently taking any medication (prescription or over the counter)?

If ‘yes’ please provide details:

Have you had a serious head injury or head trauma?

If ‘yes’ please provide details:

Do you suffer from any mental health conditions?

If ‘yes’ please provide details:

Do you suffer from any of the following medical conditions?

Chronic malabsorption syndrome
Inflammatory bowel disease
Gastroparesis (delayed stomach emptying)
Cholestasis
Pancreatitis

Do you have any medical conditions, that may contribute to your weight gain?

Cushings syndrome
Hypothyroidism
Growth hormone deficiency
Polycystic ovary syndrome
Hypothalamic damage

Is there anything else you would like to mention to our medical team which you think might be relevant?

If ‘yes’ please provide details:

Do you agree to the following?

You understand this medicine is a subcutaneous injection
You have watched the video (Product page) and are comfortable administering this medicine yourself.

At Raylane Medical, we want to assure you that you that the safety and well-being of our customers is top priority. Please upload a picture of your weight on a scale with your ID to verify that it is you.

Please see an example of the evidence we require here:

Are you aware that:

If you have not lost 5% of your initial weight within 12 weeks of treatment or if your BMI drops below 27, you should stop taking it and visit your GP for advice
If you gain weight during treatment, you should stop taking the medication and see your GP for advice

Do you agree to the following?

You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

I give my consent for Raylane Medical prescribers and/or pharmacist to access my summary care record (SCR)

I agree to read the patient leaflet before taking any medication (if prescribed).

Are you currently registered with a UK GP practice?

Please State Your GP Practice:

Do you agree that you have answered all of the above questions accurately and truthfully. You understand our prescribers will prescribe medication based on your responses, any incorrect responses or deliberate acts to misinform may be hazardous to your he