Consultation Form

Mounjaro Consultation Form (#4)

Welcome to AHMU Clinic , Begin Your weight loss medication consultation

We’ll ask a few questions to assess your eligibility, which will take around 2 minutes. When you're done, press complete and one of our clinicians will review your answers.

Are you currently using Mounjaro or Wegovy?

Yes

Please upload your Proof of Purchase from your Previous provider.

Choose File

Please upload your full body picture.

Choose File

Please upload your picture ID Proof (Driving License/ Passport) for Verification.

Choose File

Please Enter Your Date of Birth

Please Enter your sex at Birth

Male

Female

Have you ever had a reaction to any medicine?

Yes

Please Specify

Please Enter your NHS Number

Please Enter Name of your GP

Please Enter the Full Address including Post code of your GP

Address Line 1

City

County

Post Code

Country

Do you consent to share details of this order with your GP?

Yes

I agree to share consent to check my NCRS Record (National Care Record Service)

I agree!

What is your current height?

What is your current weight?

Have you been told that you have dyslipidaemia, e.g. high cholesterol?

Yes

Have you been told that you suffer from sleep apnoea?

Yes

Are you taking medication for blood pressure?

Yes

Please Name Them

Do you have diabetes?

Yes

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?

Yes

Are you breast-feeding?

Yes

Do you have any allergies ?

Yes

Please Name them

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

Yes

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

Yes

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

Yes

Do you have liver problems?

Yes

Do you have Kidney problems?

Yes

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

Yes

Do you have a current or past history of bipolar disorder?

Yes

Do you have a current or past history of depression?

Yes

Do you have any heart or circulation problems?

Yes

Do you have or have you ever had a condition affecting the circulation of blood in the brain?

Yes

Do you frequently use cocaine or other stimulants?

Yes

Are you usually a heavy drinker?

Yes

Do you have any of the following medical conditions ?

Growth hormone deficiency

Cushing’s syndrome

Hypothyroidism

Hypothalamic damage (e.g., tumour, trauma, or surgery)

None of the above

Do you have or have been diagnosed with Polycystic Ovary Syndrome - PCOS?

Yes

Have you ever had a serious head injury or head trauma?

Yes

Have you been told that you have chronic malabsorption syndrome?

Yes

Have you been told that you have Cholestasis?

Yes

Have you been told that you have Gallstones?

Yes

Have you been told that you have inflammatory bowel disease or any severe stomach or gut problem resulting in delayed stomach emptying (called gastroparesis)?

Yes

Do you have any problems with your pancreas?

Yes

Please Enter your Weight Goal

Please select a goal from the drop down list below.

How would you like to achieve this goal?

Is there anything else that you would like to inform us?

All patients completing consultation should confirm the following:

I am aware of the patient website Terms & conditions and I have agreed to continue.
I have received information on the risks and benefits of the medicine, and I have had the opportunity to ask questions. The medical information I have provided is true and accurate to the best of my knowledge, and I consent to the medicine being administered.
I understand that my personal information, including name, surname, email, telephone, date of birth (DOB), address, NHS number, and GP details, will be securely uploaded to the website’s Database for electronic storage, and it will be kept in line with data protection regulations along with the details of the consultation (i.e., medicines provided).
I authorize the collection, storage, and secure transmission of my information for the purposes mentioned above.
I acknowledge that after the consultation, the details of my medication and consultations will be accessible through my Online account, using the provided email address for login.
I understand that I can speak to a member of staff about any queries regarding the consultation or the processing of personal data for this consultation, including exercising my rights under data protection legislation.

Do you understand and give consent to the conditions to treatment.

Yes, I understand

IMPORTANT: I understand that the delivery must be accepted on the first delivery attempt. This is a temperature-controlled item and will be sent with ice packs and a temperature-controlled pouch. Orders missed cannot be returned or refunded as these cannot be reused. This is a whole-day delivery. You must stay at your delivery address the entire day regardless of the estimated delivery time provided by the courier.

Yes

Do you agree to the following?

The intended user will stop using this medicine and seek medical attention if he/she experiences any unusual side effects
The medicine is solely for use by the intended user
The intended user will read the patient information leaflet supplied with this medication

Do you agree to the above mentioned policies?

Yes, I agree

Please confirm that you are over 18 and agree to our Terms and Conditions of sale.

I am over 18 and I agree to the Terms and Conditions

Please Select your choice of treatment

Mounjaro 2.5mg KwikPen (Starter Dose) - £149.00

Mounjaro 5mg KwikPen - £ 165.00

Mounjaro 7.5mg KwikPen - £ 215.00

Mounjaro 10mg KwikPen - £ 240.00

Mounjaro 12.5mg KwikPen - £ 260.00

Mounjaro 15mg KwikPen - £ 280.00

Welcome to AHMU Clinic , Begin Your weight loss medication consultation

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