Order | MedPal Clinic

Have you taken any injectable weight loss medication in the last 6 months? (*)

This could be from MedPal or any other prescriber. You may be able to maintain or increase your dose.

Yes

No

What medication did you take? (*)

Mounjaro (tirzepatide)

Wegovy (semaglutide)

Other

When did you start this dose? (*)

When did you last take this dose? (*)

Would you like to stay at the same dose, increase, or decrease?

Stay at the same dose

Increase my dose

Decrease my dose

Name and Contact Information

First Name (*)

Last Name (*)

Email (*)

Mobile Number (*)

+44

Physical Information

Height (cm) (*)

Weight (kg) (*)

Date of Birth (*)

Ethnicity Information

We request this information because healthy weight ranges vary for different ethnic backgrounds.

Asian or Asian British

Black, African, Caribbean or Black British

Middle Eastern

Mixed (any mixed or multiple backgrounds)

White (any white backgrounds)

Other ethnic group

Prefer not to say

Biological sex at birth (*)

We require this information because weight loss drugs work differently between males and females.

Male

Female

Home Address (*)

We require your residential address, where you are registered with your GP.

Address Lookup

Question 1 of 0

Are you currently pregnant, breastfeeding, or planning a pregnancy in the next 3 months?

GLP-1 medications (such as Mounjaro and Wegovy) should not be used during pregnancy or while breastfeeding. If you are planning a pregnancy, you must stop using GLP-1 medication at least 3 months before.

Yes

No

Question 2 of 0

Are you currently taking any oral contraceptives?

Mounjaro may reduce the effectiveness of the oral contraceptive pill. This means you’ll need to use other forms of contraception (such as condoms or an IUD/implant) while taking Mounjaro to prevent unplanned pregnancy.

Yes

No

Question 3 of 0

Do you currently, or have you ever had, any of the following conditions?

For your safety, it's important to tell us about your medical history. When you order, we'll tell your GP you're starting a new treatment, and we may check medical details with them, if necessary.

Prediabetes

You have ticked prediabetes. Are you currently taking insulin or any oral or injectable medication such as metformin?

If yes, it’s very important to let us know. GLP-1s can affect insulin requirement and blood sugar regulation.

Yes

No

Type 1 Diabetes

You have ticked Type 1 Diabetes. Are you currently taking insulin or any oral or injectable medication such as metformin?

If yes, it’s very important to let us know. GLP-1s can affect insulin requirement and blood sugar regulation.

Yes

No

Type 2 Diabetes

You have ticked Type 2 Diabetes. Are you currently taking insulin or any oral or injectable medication such as metformin?

If yes, it’s very important to let us know. GLP-1s can affect insulin requirement and blood sugar regulation.

Yes

No

High blood pressure

High cholesterol

Heart or blood vessel disease (including previous heart attack)

Previous stroke

Obstructive sleep apnoea

Acid reflux or gastro-oesophageal reflux disease (GORD) (and taking regular medication)

Metabolic dysfunction-associated steatotic liver disease (MASLD). Previously known as non-alcoholic fatty liver disease

Osteoarthritis

Depression (and taking regular medication)

Polycystic ovary syndrome (PCOS)

Pancreatitis

Eating disorder, such as anorexia or bulimia nervosa

Do you ever make yourself sick because you feel uncomfortably full?

Yes

No

Do you worry that you have lost control over how much you eat?

Yes

No

Have you recently lost more than one stone in a 3-month period?

Yes

No

Do you believe yourself to be fat when others say you are too thin?

Yes

No

Would you say that food dominates your life?

Yes

No

Weight loss procedures or surgery in the last 12 months

Personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2 (MEN2) syndrome

Any form of cancer that is currently being treated by a specialist

Active retinopathy

Heart failure with shortness of breath at rest

Chronic kidney disease with reduced function (eGFR less than 30ml/min - you can find this information on your kidney function blood test)

Severe gastrointestinal disease, including inflammatory bowel disease (eg ulcerative colitis or Crohn’s disease), or gastroparesis (delayed stomach emptying)

Chronic malabsorption syndrome (problems absorbing nutrients)

Liver cirrhosis or a liver transplant

An endocrine (hormone) disorder, such as overactive thyroid disease, acromegaly, Addison’s disease, Cushing’s syndrome, congenital adrenal hyperplasia, or a growth hormone disorder

Treatment or rehabilitation for excessive alcohol use

Any cognitive or memory impairment, such as dementia, that may impact the ability to make decisions

None of the above

Question 4 of 0

Have you ever experienced an allergic reaction to any of the following medications?

Mounjaro (tirzepatide)

Wegovy/Ozempic (semaglutide)

Saxenda/Victoza (liraglutide)

I have other medication allergies

None of the above

Question 5 of 0

Do you have any of the following gallbladder issues?

Gallstones that have not been removed

Blocked bile flow (cholelithiasis)

Gallbladder infection (cholecystitis)

Gallbladder surgery in the past 12 months

None of the above

Question 6 of 0

Are you currently taking any of the following medications?

It's important to let us know about any of these medications to help us provide a safe and effective treatment.

Amiodarone

Carbamazepine

Ciclosporin

Clozapine

Digoxin

Fenfluramine

Lithium

Mycophenolate mofetil

Oral methotrexate

Phenobarbital

Phenytoin

Somatrogon

Tacrolimus

Theophylline

Warfarin

None of the above

Terms and Conditions

All orders are subject to clinical approval. Clinicians may request further information where necessary.

You must agree to the following conditions:

I confirm that the information I have provided is true and accurate, and I understand it will be used by prescribers to decide whether treatment is suitable for me.
I understand that injectable weight loss treatments like Mounjaro or Wegovy must not be combined with other weight loss medicines and can increase the risk of pancreatitis or gallbladder issues. If I have severe abdominal pain, vomiting, or jaundice, I will seek urgent medical help.
I confirm that I will adhere to a structured diet and exercise plan, to be followed alongside my prescribed medication, and I understand that both are essential components of this weight-management programme.
I understand that severe diarrhoea or vomiting may affect contraceptive effectiveness, and I will seek medical advice if this happens. I will also stop treatment and contact a doctor if I experience mood changes or mental health issues.
I confirm this treatment is for my own use only, and I will read the patient information leaflet before use.
I will inform MedPal and my GP of any side effects, new medications, or changes to my health during treatment.
I agree that MedPal may notify my GP that I am taking GLP-1 medication, and may request or share relevant information with my GP if required.
I consent to my personal and health data being processed in line with the privacy policy, agree to the Terms and Conditions, and confirm I am over 18.
I give explicit consent for MedPal’s clinicians, who are providing my care, to view my NHS Summary Care Record (including Additional Information where available) via NHS systems for the purposes of direct care, and to document relevant information back to my GP. I understand I can withdraw this consent at any time.

I agree to all of the above.

Order Summary

Mounjaro (tirzepatide) - -
One month supply

£ -

Shipping

£ -

Total (VAT exempt)

£ -

Payment Details

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Mounjaro (tirzepatide) Order Form

Have you taken any injectable weight loss medication in the last 6 months? (*)

Name and Contact Information

Physical Information

Ethnicity Information

Biological sex at birth (*)

Home Address (*)

Question 1 of 0

Question 2 of 0

Question 3 of 0

Question 4 of 0

Question 5 of 0

Question 6 of 0

Terms and Conditions

Order Summary

Payment Details