Your Consultation – emedspharmacy.co.uk

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Please fill in the weight loss consultation below

What is your height (cm)/feet/inches

Value must be between 100cm and 220cm

Value must be between 3ft 4in and 7ft 2in

Switch to ft, in

What is your weight (kg)/ stones/pounds

Value must be between 40kg and 250kg

Value must be between 6st 4lbs and 39st 6lbs

Switch to st, lb

Are you between 18 to 74 years old

Yes

⚠ Important Notice: We are sorry this is not for you. You are not eligible for this treatment, as it is only prescribed to individuals aged 18 to 74. We advise contacting your GP to explore safe and effective weight management options tailored to your needs.

What is your ethnic background? (Choose one)

Do you currently have or have you previously had any of the following?

Prediabetes
Type 2 diabetes
High blood pressure
High cholesterol
Heart or blood vessel disease (including previous heart attack)
History of stroke
Obstructive sleep apnoea Osteoarthritis Metabolic dysfunction associated steatotic liver disease (MASLD) (formerly fatty liver disease)
Polycystic ovary syndrome (PCOS) or infertility

Yes

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

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Reason: Unfortunately, we cannot prescribe any of these treatments as you have previously experienced an allergic reaction. Please speak with your GP for advice and support on safe and effective weight management options.

Are you currently

Pregnant ,Breastfeeding or Planning to become pregnant

GLP-1 medications (such as Mounjaro and Wegovy) are not recommended for use during pregnancy or while breastfeeding.

Yes

GLP-1 medications should not be used during pregnancy or while breastfeeding. These may reduce the effectiveness of oral contraceptives. Use a barrier method (e.g., condoms) during treatment and for 4 weeks after any dose increase or switch to non-oral methods like the coil or implant. Medicine Stop before pregnancy Semaglutide (Wegovy) 2 months Tirzepatide (Mounjaro) 1 month

Pregnant ,Breastfeeding or Planning to become pregnant

GLP-1 medications (such as Mounjaro and Wegovy) are not recommended for use during pregnancy or while breastfeeding.

Do you currently have or have ever been diagnosed with

Pancreatitis
Liver cirrhosis or received a liver transplant
Any cancer under active specialist treatment
Eye disease due to diabetes (retinopathy)
Heart failure with shortness of breath at rest
Chronic kidney disease (eGFR < 30)
Chronic digestive issues (e.g., Crohn’s, ulcerative colitis, gastroparesis)
Treatment for alcohol dependency
Malabsorption syndromes (problems
Endocrine disorders (Overactive thyroid awaiting radioactive iodine or surgery, Addison’s disease,acromegaly, Cushing’s syndrome, congenital adrenal hyperplasia, or a growth hormone disorder, etc.)
Cognitive or memory impairments (e.g., dementia)

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Reason: Unfortunately, we cannot prescribe this treatment if you have any of the listed medical conditions. Please speak with your GP for advice and support on safe and effective weight management options.

Have you experienced any of the following related to your gallbladder?

Gallstones (not removed)
Blocked bile flow (cholelithiasis)
Gallbladder infection (cholecystitis)
Gallbladder surgery within the last 12 months

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Reason: Unfortunately, we cannot prescribe this treatment if you have any gallbladder issues. If you have had gallbladder surgery within the past 12 months, we may be able to reassess your eligibility once a full year has passed since your operation. Please speak with your GP for advice and support on safe and effective weight management options.

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)
Endoscopic sleeve gastroplasty
Gastric balloon
Biliopancreatic diversion or duodenal bypass

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Sorry, we cannot prescribe this treatment as your body needs to recover from any procedures first. If you’ve had bariatric weight-loss surgery in the past 12 months, we may be able to help you when a full year has passed since your operation. We recommend asking your GP for support with weight loss.

Have you ever experienced an eating disorder, such as anorexia or bulimia nervosa?

If you suspect you may have an eating disorder — even if you’ve never received a formal diagnosis — please answer ‘yes.’ Being honest is important for ensuring your health and safety.

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Reason: Unfortunately, we cannot prescribe this treatment if you have, or have ever had, an eating disorder. Please speak with your GP if you need support with weight loss or managing an eating disorder.

Have you been diagnosed with type 1 diabetes?

If so, please let us know. GLP-1 medications can impact insulin needs and blood sugar control, and should only be used by individuals with type 1 diabetes under the supervision of a specialist diabetes care team.

Yes

If you have type 1 diabetes, are you currently using insulin?

Yes

If yes, please let us know. This treatment can affect your insulin requirements and blood sugar regulation. GLP-1 medications should only be prescribed to individuals using insulin under the supervision of a diabetes care team.

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

Yes

⚠ Important Notice We do not have a suitable treatment for you at this time. Reason: Unfortunately, we cannot prescribe this treatment due to the risk of low blood sugar (hypoglycaemia). Please speak with your GP for advice and support on safe and effective weight management options.

Are you currently taking any of the following?

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

Yes

⚠ Important Notice We do not have a suitable treatment for you at this time. Reason: Unfortunately, we cannot prescribe this treatment because it may interact with certain medications and may not be safe for you. Please speak with your GP for advice and support on safe and effective weight management options.

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

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Reason: Unfortunately, we cannot prescribe this treatment if you have any of these conditions. Please speak with your GP for advice and support on safe and effective weight management options.

Are you currently taking any medication to treat a thyroid condition?

Yes

⚠ Important Notice: Weight-loss treatments, such as GLP-1 medications, can affect digestion and how your stomach empties. This may impact the absorption of your thyroid medications. It is important to inform your doctor if you are using GLP-1 treatments, as they may need to monitor your thyroid levels more frequently and adjust your thyroid medication dose accordingly. Please continue taking your thyroid medications exactly as prescribed while using GLP-1 treatments like Wegovy and Mounjaro.

Have you used any injectable weight-loss treatment medication in the past 6 months?

(This can be from eMeds or another provider)

Yes

To ensure your treatment is safe and effective, we need to confirm that you are starting on the correct dose.

Do you understand that you may be asked to provide proof of a prescription from another provider if either of the following applies:

● This is your first order of injectable weight-loss medication from eMeds and you are not requesting the starter dose.

● Your last order from Emeds was more than 6 months ago, and you have been receiving treatment from another provider since then.

Have you experienced any of the following recently?

Thoughts of self-harm or suicide, depression, anxiety, or mood disorder

Yes

There is no proven link between GLP-1s and mental health changes, but monitoring is ongoing.

If you are due to have surgery, inform your doctor and anaesthetist that you are taking a GLP-1 medication, as it may slow stomach emptying and increase the risk of aspiration under anaesthesia.

Injectable weight-loss treatments such as Mounjaro and Wegovy may increase the risk of developing pancreatitis, gallstones, or gallbladder issues.

If you experience severe abdominal pain (especially if it radiates to your back), vomiting, or worsening symptoms, seek urgent medical attention by calling 999 or going to A&E.

Do you understand and agree?

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Consent Required: You must acknowledge and agree to this before proceeding.

If you are sexually active, please note that Mounjaro may reduce the effectiveness of the oral contraceptive pill.

You should use an additional method of contraception (e.g. condoms, IUD, or implant) to prevent unplanned pregnancy while taking Mounjaro. Do you understand and agree?

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Consent Required: You must acknowledge and agree to this before proceeding.

Severe diarrhoea (lasting more than 24 hours) or vomiting (within 3 hours of taking your oral contraceptive pill) may affect its effectiveness.

You may need to take an additional dose and should call 111 for medical advice to avoid unplanned pregnancy.

Do you understand and agree?

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Consent Required: You must acknowledge and agree to this before proceeding.

Injectable weight-loss treatments (such as Mounjaro and Wegovy) should not be used alongside other weight-loss medications or treatments.

Do you understand and agree?

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Consent Required: You must acknowledge and agree to this before proceeding.

GLP-1 weight-loss treatments may be associated with mood changes.

If you experience low mood, suicidal thoughts, thoughts of self-harm, or other concerning mental health symptoms, you should stop treatment and seek medical advice from your GP or mental health team.

Do you understand and agree?

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Consent Required: You must acknowledge and agree to this before proceeding.

Do you agree to the following statements?

● The information I have provided is true and accurate to the best of my knowledge.

● This information will be used by eMeds prescribers to assess whether treatment is suitable for me.

● I understand that providing inaccurate or incomplete information may result in being refused treatment or being prescribed medication that is not appropriate.

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Consent Required: You must acknowledge and agree to this before proceeding.

Do you agree to the following?

● This treatment is solely for my own personal use.

● I will read the patient information leaflet supplied with the medication.

● I will contact eMeds and inform my GP if I experience any side effects, begin new medications, or if my health status changes during treatment.

● I give consent for Emeds to notify my GP that I am using GLP-1 weight-loss medication and to allow my GP to share relevant information with Emeds if necessary.

● I give permission for Emeds to access additional medical information from my GP via Summary Care Records., if required.

● I consent to the collection, processing, and secure storage of my personal and health information for the purpose of evaluating and managing my treatment.

● I understand that my information may be shared with relevant healthcare professionals for the purpose of my care.

● I understand that I can withdraw my consent at any time and will be provided with guidance on how to do so.

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Consent Required: You must acknowledge and agree to this before proceeding.

Do you consent to us contacting your GP if needed for clinical safety?

Yes

GP Name, GP Practice Name, GP Phone Number, GP Address

I agree that the information I have provided is correct and I give consent to Emeds Pharmacy to verify this information with my SCR (Summary Care Records) if required.

⚠ Important Notice: We do not have a suitable treatment for you at this time. Consent Required: You must acknowledge and agree to this before proceeding.

Consent to verification follow-up by clinician

Yes

Consent to share details with GP

Yes

⚠ Important Notice: We do not have a suitable treatment for you at this time. Reason: Unfortunately, we cannot proceed with prescribing this treatment unless you consent to us sharing relevant health information with your GP to ensure safe and coordinated care. Please speak with your GP for advice and support on weight management options.

Any questions or concerns before beginning treatment?

Yes

Please describe

Please complete all required questions.

Annie



The pharmacist was amazing. He helped answer all my questions regarding weight loss injections. He took my blood pressure made sure everything was perfect. Answered questions I need to know definitely return felt confident in his knowledge

John Williamson

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The consultant was good and had the information I was looking for and I am going to enjoy trying this treatment to see if it helps me to lose weight thanks.

Lynda

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Reassuring start to my weight loss journey. Given appointment quickly, and reassuring that a couple of things were checked with GP. Everything explained clearly, and my questions answered. I was assured that I should be in touch with pharmacist if there were any problems.

Danny Rawlings

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Mounjaro weight loss medication. Very professional, helpful, and reassuring Would recommend to anybody looking to purchase weight loss medication.

Anthony

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My weight loss journey The pharmacist was very helpful and went into detail regarding the weight loss treatment, explaining any possible side effects that may happen.

Mr Keith Allan

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Weigh loss management we had a lot of questions,and answers were provided, made us feel at ease and ensured that we were happy to go a head with the weight loss plan, We felt that any other issues we have we can contact them any time.

FeeP



A thoroughly positive experience My weight loss consultation was a thoroughly positive experience. From the very first phone conversation to the end of the introductory consultation, Jane gave me all the relevant information and really listened to my questions and concerns.

Charles Terry



Sai was very understanding of my situation and reasons for taking advantage of the weight loss programme. He explained clearly what was involved and gave additional support in terms of the diet I should try to follow.

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