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Patient Consultation & Medical History
Full Name*:
Date of Birth*:
Are you on mounjaro or not?*:
Select...
Yes
No
Weight (kg)*:
Height (cm)*:
Calculated BMI:
Do you have diabetes?*
Select...
Yes
No
Are you currently pregnant, breastfeeding, or planning to become pregnant?*
Select...
No
Yes
Do you have any of the following conditions?
Thyroid cancer
Pancreatitis
Kidney/Liver disease
Eating disorder
None
Are you currently taking any medications? List them:
Which strength of Mounjaro are you looking for?*
Select one
2.5mg
5mg
7.5mg
10mg
12.5mg
15mg
Upload Valid Proof of ID
Upload Previous Prescription
Upload a short video (on scale & verification)
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City*:
Postcode*:
Mobile Number* (+44...):
Invalid UK phone number.
Email*:
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