New Weight Loss (Injectables)

About You

To help us understand that one or more of our treatment options are right for you, please answer the following questions. If you get stuck or need any help, you can contact us.

Are you aged between 18 and 74 years old?

Yes

Please enter your HEIGHT and WEIGHT to check your Body Mass Index (BMI).

Treatment can only be provided if your BMI is above 30. Alternatively, you must have a BMI of 27 or over and a health problem that can affect your weight such as high blood pressure, asthma or pre-diabetes.

Please select either Metric or Imperial measurements :

Metric (Meters and Kilograms)
Imperial (Feet and Pounds)

Height

feet inches

Weight

stone lbs

Check BMI

BMI Calculation :

Do you have any of the following conditions:

Diabetes/Prediabetes
High Blood Pressure
High Cholesterol
Asthma / COPD
PCOS
Obstructive sleep apnea
Low mood associated with your weight.

The presence of any of the above conditions means you might be suitable for treatment with a lower minimum BMI of 27.

Yes

If you have diabetes, are you on any injections or tablets to control your blood sugar, other than metformin?

Yes

About your Health and Current Medication

To help us understand that one or more of our treatment options are right for you, please answer the following questions. If you get stuck or need any help, you can contact us.

Have you experienced an allergic reaction to Wegovy, Semaglutide, Liraglutide or Mounjaro.

Yes

Have you ever suffered from an eating disorder such as Anorexia Nervosa or Bulimia?

Yes

Are you pregnant, breastfeeding or intending to become pregnant or start breastfeeding whilst taking this medication?

Yes

Have you been diagnosed with any of the following?

Acromegaly or any growth hormone problem
Chronic Malabsorption Syndrome
Cushings Syndrome
Gallbladder, Bile duct or Pancreas disease
Heart Failure
Kidney Disease
Liver Disease
Multiple Endocrine Neoplasia
Pancreatitis
Personal or Family History of Thyroid Cancer

Yes

Are you CURRENTLY taking Wegovy or Mounjaro?

If yes please provide details of:

Name of medicine
Strength
Date last dose taken

You may be required to provide evidence of your previous dose before we can prescribe a higher strength. This can be a photograph of the medicine box showing the label or alternatively please forward a copy of your previous confirmation email to verify@boltpharmacy.co.uk

Yes

Have you PREVIOUSLY taken or CURRENTLY taking any other medication for weight loss?

Please include:

Name of medicine and strength.
Length of treatment.
When you took the last dose.
Reason for stopping if no longer taken.

Yes

Are you taking medication or steroids to treat your thyroid?

Please note: Changes to eating patterns can affect the absorption of these medications. You should continue to take these medications according to your usual routine whilst using Mounjaro or Wegovy.

Yes

Are you taking any of the following medications?

Acarbose, Alogliptan, Canagliflozin, Dapagliflozin, Empagliflozin, Ertugliflozin, Fenfluramine, Glibenclamide, Gliclazide, Glimepiride, Glipizide, Insulin, Linagliptin, Orlistat, Pioglitazone, Repaglinide, Saxagliptin, Sitagliptin, Somatrogon, Tolbutamide, Vidagliptin.

Yes

Are you currently taking any other medication

This includes over the counter, prescription or recreational drugs?

Yes

Our Terms and Conditions

Please ensure you have read, understood and agree to the following information.

Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice?

Yes

Do you understand that injectable weight loss medications should not be used with other weight loss medications?

Yes

Do you understand if you develop any lumps in the neck or a hoarse voice whilst taking this medication, you should stop the medication and speak to your doctor?

Yes

Do you understand that weight loss has been associated with a lowering of mood (depression), and if you are experiencing this, you should stop the medication and speak to your doctor?

Yes

Do you understand that this medication should not be used by men or women that are trying to conceive or pregnant. You must discontinue treatment at least 2 months before trying for a child.

Yes

As part of regulatory requirements for weight loss injections, you may be required to submit a recent photograph of yourself . Do you agree to send this if requested?

Please see our FAQs page for more information.

Yes

Do you consent to us sharing consultation information with your GP? (Required)

Yes

Do you agree to the following?

To Inform both us and your GP about any treatment-related side effects, the initiation of new medication, or changes in your medical conditions during the course of treatment.
To read the patient information leaflet provided with your medication before using your new treatment. If you have any questions you can contact our support team or your GP.
The prescribed treatment is intended exclusively for your personal use.
You have provided accurate and truthful responses to all the preceding questions.
You acknowledge that our prescribers rely on your responses as truthful and honest to make prescribing decisions and recognise that inaccurate information may result in serious health risks.

Yes

All Conditions

Backup 28/04/24 Weight Loss (Injectables)

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Backup 28/04/24 Weight Loss (Injectables)

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