Wegovy injection - MyChemistPlus

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Consultation

Eligibility

What is your sex registered at birth?(Required)

Male

Female

What is your ethnic background? (We ask because weight-related health risks occur at a lower BMI in some ethnic groups, and this changes the eligibility thresholds we apply.)(Required)

White

South Asian

Chinese

Black African

African-Caribbean

Mixed

Multiple ethnic groups

Prefer not to say

Other

Please provide your current height and weight using your preferred unit system (Measured within the last 7 days.)

Which unit system do you prefer?(Required)

Metric (kg / cm)

Imperial (st & lb / ft & in)

Weight — Stones

Weight - Pounds

Please enter a number from 0 to 13.

Weight (kg)

Height (cm)

Height — Feet

Height — Inches

Please enter a number from 0 to 11.

Calculated BMI(Required)

This field is hidden when viewing the form

Weight in kg (converted)

This field is hidden when viewing the form

Height in cm (converted)

Calculated BMI (Imperial)

Have you been diagnosed by a doctor with any of the following weight-related conditions?(Required)

Type 2 diabetes or pre-diabetes

High blood pressure (hypertension)

High cholesterol (dyslipidaemia)

Obstructive sleep apnoea

Cardiovascular disease (e.g. heart disease, previous heart attack or stroke)

Polycystic Ovary Syndrome (PCOS)

Non-alcoholic fatty liver disease (NAFLD)

None of the above

Do you have, or have you ever had, any of the following?(Required)

Type 1 diabetes

Medullary thyroid cancer, or a family history of medullary thyroid cancer or MEN 2 (a rare inherited endocrine condition)

Pancreatitis (inflammation of the pancreas)

Severe kidney disease or kidney failure

Severe liver disease

Inflammatory bowel disease (Crohn’s disease or ulcerative colitis) or severe stomach/gut problems (e.g. gastroparesis)

A condition that stops you absorbing food properly (chronic malabsorption syndrome)

Cholestasis (a problem with bile flow from the liver)

Gallbladder disease or gallstones

None of the above

A pharmacist may be in touch with you to discuss if this treatment is suitable for you.

Do you have any other medical conditions, or have you had any operations, that you have not already told us about?(Required)

Yes

Please give brief details:(Required)

Have you ever been diagnosed with, or received treatment for, an eating disorder (such as anorexia nervosa, bulimia nervosa, or binge eating disorder), or do you currently have thoughts of self-harm or suicide?(Required)

Yes — an eating disorder (past or present)

Yes — thoughts of self-harm or suicide

Yes — both

None of the above

Unfortunately, we are unable to provide weight-loss treatment through this service because you have indicated a past or present eating disorder. Weight-loss medicines may not be suitable where there is a history of disordered eating, and a full assessment by an appropriate healthcare professional is required.
Please arrange an appointment with your GP, who can assess your physical and mental health and refer you to a specialist eating-disorder service where appropriate. You can also contact Beat for confidential information and support. In England, the Beat Helpline is available on 0808 801 0677, Monday to Friday, 3pm to 8pm.
For urgent medical or mental-health advice, contact NHS 111. If you or someone else is in immediate danger, call 999 or attend A&E.

Unfortunately, we are unable to provide treatment through this service because you have indicated that you are currently experiencing thoughts of self-harm or suicide. Your safety is the immediate priority, and you need support from a healthcare professional who can assess you properly.
Please contact NHS 111 and select the mental-health option, or request an urgent appointment with your GP. You can also call Samaritans free of charge, at any time of the day or night, on 116 123.
If you feel unable to keep yourself safe, have seriously harmed yourself, have taken an overdose, or believe there is an immediate risk to you or another person, call 999 or go to A&E now.

Unfortunately, we are unable to provide weight-loss treatment through this service because you have indicated a past or present eating disorder and current thoughts of self-harm or suicide. Your safety is the priority, and you require assessment and support from an appropriate healthcare professional.
Please contact NHS 111 and select the mental-health option, or request an urgent appointment with your GP. You can also contact Samaritans free at any time on 116 123 and Beat on 0808 801 0677 for eating-disorder support.
If you feel unable to keep yourself safe, have harmed yourself, taken an overdose, or are in immediate danger, call 999 or attend A&E now.

Are you currently using, or have you used in the last 4 weeks, any weight loss medicine — from any pharmacy, clinic, or online provider? (e.g. Mounjaro, Wegovy, Ozempic, Saxenda, orlistat, Xenical, Alli)(Required)

Yes

Which treatment and dose, and when was your last dose?

Do you currently take any medicines, including anything prescribed by a doctor, bought over the counter, or herbal remedies?”(Required)

Yes

Do you take any of the following?(Required)

Insulin, or medicines for diabetes (e.g. gliclazide, metformin)

Warfarin or other blood thinners (anticoagulants)

Levothyroxine (thyroid hormone)

Ciclosporin (immunosuppressant)

Medicines for epilepsy or seizures

HIV medicines (antiretrovirals)

Amiodarone (heart rhythm medicine)

The contraceptive pill (oral contraceptives)

None of these

A pharmacist may be in touch with you to discuss if this treatment is suitable for you.

Please detail what you are taking, letting us know how often and dosing where possible:(Required)

Are you currently pregnant, trying to become pregnant, or breastfeeding?(Required)

Yes — I am pregnant

Yes — I am trying to become pregnant

Yes — I am breastfeeding

Unfortunately, weight-loss treatment is not suitable if you are pregnant, trying to become pregnant, or breastfeeding. Please speak to your GP or midwife for appropriate weight-management advice and support. Thank you.

Important: Weight loss treatments can make the contraceptive pill less effective. Mounjaro slows the emptying of the stomach, which can reduce how well the pill is absorbed — you should use an additional barrier method (e.g. condoms), or switch to a non-oral method, for 4 weeks after starting and for 4 weeks after each dose increase. If you take orlistat (Orlistat, Xenical, or Alli) and experience severe diarrhoea, your pill may not be absorbed — use an additional barrier method during illness.(Required)

I understand and agree to follow this advice

Have you tried to lose weight through diet and lifestyle changes (e.g. reduced-calorie diet, increased exercise) before requesting medication?(Required)

Yes — I have tried diet and lifestyle changes

No — this is my first structured attempt

Weight-loss medication should be used alongside a reduced-calorie diet and increased physical activity, rather than as a replacement for these measures. By continuing, you confirm that you understand that diet and lifestyle changes remain an important part of your treatment.(Required)

I understand and agree to follow this advice

These questions help us make sure this treatment is safe for you. Please answer honestly — they are reviewed by a clinician, not a computer alone.(Required)

I make myself sick because I feel uncomfortably full

I worry I have lost control over how much I eat

I have lost more than one stone (6.5 kg) in the last 3 months

I believe I am fat even when others say I am too thin

Food dominates my life

None of the above

Is there anything else you would like the clinician to know about your health, lifestyle, or weight loss goals?(Required)

Yes

Please provide further details:

Consent & Declarations

• I confirm that all the information I have given is truthful, accurate, and about me. I understand that giving false information (including my height or weight) could seriously harm my health.
• I confirm that this medicine is for my own personal use only and will not be shared with, or bought for, anyone else.
• I understand that completing this consultation does not guarantee a prescription. A qualified prescriber will review my answers and will only prescribe if it is safe and appropriate. If treatment is not approved, I will not be charged.
• I understand that this medicine works alongside a reduced-calorie diet and increased physical activity, not instead of them.
• I agree to read the Patient Information Leaflet (PIL) supplied with my medicine before using it, and to follow the dosage instructions exactly.
• I will stop taking the medicine and seek urgent medical help (NHS 111, or 999 in an emergency) if I experience severe, persistent stomach/abdominal pain (possible pancreatitis), signs of a serious allergic reaction (facial swelling, difficulty breathing), or become pregnant during treatment.
• I understand that my GP will be informed of this treatment using the GP details I provide at checkout, and I consent to this. I understand that proceeding to payment authorises this contact.
• I consent to the prescriber contacting me for further clinical information if required, and I understand they may access or request relevant medical records to support a safe prescribing decision.
• I consent, where applicable, to the clinical team accessing my NHS Care Record Service (NCRS) to verify the information I have provided and to support a safe prescribing decision. I understand this access is limited to what is necessary for my care and is recorded in line with NHS guidance.
• I understand that if I do not lose enough weight after 12 weeks on treatment (at least 5% of my starting weight for orlistat-based products and maintenance-dose GLP-1/GIP treatments), treatment should be stopped and I will be advised accordingly.
• I agree to the MyChemistPlus terms of service and privacy policy, and consent to identity checks if required.

Consent(Required)

I agree to the terms and conditions set out above.(Required)