Mounjaro (Tirzepatide) Eligibility & Consultation Form

Please complete this form truthfully and to the best of your knowledge. Your responses will help our clinical team decide whether Mounjaro is suitable for you. All answers are confidential.

Providing inaccurate or incomplete information may put your health at risk. This form does not guarantee a prescription - a licensed prescriber will review your answers and may request further information.

Personal Details

Full Name

Date of Birth (DD/MM/YYYY)

Sex at Birth
--- Please select ---MaleFemaleIntersexPrefer not to say

Email Address

Phone Number

Full Address & UK Postcode

Physical Measurements

Height (cm)

Weight (kg)

Your BMI will be calculated automatically:

BMI:-

Medical Conditions

Do you have any of the following weight-related health conditions? (tick all that apply)
Hypertension (high blood pressure)Prediabetes or impaired glucose toleranceType 2 diabetesDyslipidaemia (high cholesterol/triglycerides)Obstructive sleep apnoea (OSA)Non-alcoholic fatty liver disease (NAFLD / MASLD)Osteoarthritis in weight-bearing jointsCoronary heart disease or heart failurePolycystic ovary syndrome (PCOS)Depression linked to weightOther (please specify)

Other (please specify)

Medical History & Risk Factors

Do you have any of the following? (tick all that apply)
Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN2)History of pancreatitisCurrently pregnant, planning pregnancy, or breastfeedingSevere gastrointestinal disease (e.g. gastroparesis)Known allergy to tirzepatide or related medicationsAdvanced kidney disease (eGFR < 30) or on dialysisNone of the above

Please list any current medications (including over the counter and herbal supplements).

Please list any allergies (medication, food, environmental).

Lifestyle Support

Are you currently receiving any professional support for weight management?
YesNo

If yes, please describe (e.g., dietitian, GP, weight-loss group, psychological support).

GP Details

GP Name

GP Practice Name & Address

Are you happy for us to inform your GP about your treatment?
YesNo

Consent

I understand that Mounjaro is not a quick fix and should be combined with lifestyle changes for best results.
I consent to my data being processed for medical purposes in accordance with GDPR.

Please note that submitting this form initiates the consultation process and is not a guarantee of a prescription. Your information will be reviewed by a licensed prescriber who will determine your eligibility for Mounjaro.