“Mounjaro Pre-Clinical Consultation”

Mounjaro (tirzepatide) Pre‑Clinical Consultation for Kepple Lane Pharmacy

Please complete this form to assess eligibility and safety before starting Mounjaro (tirzepatide). Your answers help us check clinical suitability, identify contraindications, and plan monitoring.Note: In England, tirzepatide for weight management is recommended alongside reduced‑calorie diet and increased physical activity for adults meeting BMI/comorbidity criteria, with lower BMI thresholds for certain ethnic groups;
Section A - Patient Details

Patient Information
Name*

First NameLast Name
Date of Birth *

DayMonthYear
Date
Email*
example@example.com
Phone Number

Area CodePhone Number
Mobile Number *
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Height (cm)*
Weight (kg)*
BMI
Ethnic background*

South Asian (e.g., Bangladeshi, Indian, Pakistani)ChineseOther AsianMiddle EasternBlack African or African‑CaribbeanWhite (including White British, Irish, other White backgrounds)Mixed or multiple ethnicitiesOtherPrefer not to say
*NICE recommends using a lower BMI threshold (usually −2.5 kg/m²) for people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African‑Caribbean backgrounds

Section B: Identity & Weight Verification

Why we ask for proof: For safe remote prescribing, we must confirm identity and age. You can upload a government ID or an NHS document. Please cover any numbers we do not need; we only require your name, photo and date of birth.
How would you like to verify your identity?*

Upload a photo of a government ID (passport or UK driving licence)Upload a selfie holding your ID (face and ID visible)
Upload your identity document (Please cover any ID numbers; we only need name + photo + date of birth.)

Accepted types: jpg, jpeg, png, pdfMax size: 10 MB
Cancelof
How would you like to verify your current weight?*

Upload GP/NHS App record showing height/weight (with date)Video call to confirm scale display (no face)Upload photo of scale display (no face)
Important: We must independently verify height/weight/BMI for weight‑management medicines. Verification may be done via records, pharmacy weigh‑in, or two‑way communication. We do not require facial images.
Upload your GP/NHS record (height & weight, date visible)

Accepted: pdf, jpg, png • Max size: 10 MB
Cancelof
Upload photo of your scale display (no face)

Please include today’s date and your initials on a paper next to the display.
Cancelof
We’ll schedule a short video call to confirm the scale reading

Section E — Diabetes Medications

Only complete if you are diagnosed with Type 1 or Type 2 Diabetes
Are you using insulin?*

YesNo
Are you taking other diabetes medicines besides metformin/insulin (e.g., sulfonylureas, SGLT2, DPP‑4, GLP‑1)?*

YesNo
Tirzepatide may require dose adjustments of insulin or sulfonylureas to reduce hypoglycaemia risk.

Section G — Lifestyle

Lifestyle Factors
Smoking status*

CurrentFormerNever
Alcohol use*

NoneOccasionalRegular
Please provide number of units per week
Section H — Upload recent blood test results (optional but recommended)

Upload Recent Results
HbA1c, eGFR/Creatinine, LFTs, Lipid profile, TSH/Free T4. Baseline labs are recommended before starting tirzepatide; ongoing monitoring supports safe treatment
Upload recent blood tests

Requested: HbA1c, eGFR/Creatinine, LFTs, Lipid profile, TSH/Free T4.Baseline labs are recommended before starting tirzepatide; ongoing monitoring supports safe treatment
Cancelof

Section I — Patient Education & Consent

Important Safety Information — Please read and confirm
Key points:

• Tirzepatide should not be used if you or a family member have Multiple Endocrine Neoplasia type 2 (MEN2) or medullary thyroid carcinoma (MTC). Report any neck lump, hoarseness, trouble swallowing, or shortness of breath.

• Use caution and seek urgent advice for severe abdominal pain, persistent vomiting, jaundice, or signs of dehydration (risk of pancreatitis and gallbladder issues).

• Oral contraceptives may be less effective when starting or increasing dose; use non‑oral contraception or add barrier protection for 4 weeks after initiation and 4 weeks after each dose increase.

• Treatment should be combined with dietary changes and physical activity and monitored regularly per NHS guidance.
Consent*

I confirm the information I have provided is true and accurate.I understand tirzepatide must not be used with a personal/family history of MEN2/MTC.I understand the contraception advice and will follow it if applicable.I consent to my data being used to assess treatment suitability and for communication with my GP if needed.I agree that this treatment is for my personal use only and I will read the patient information leaflet supplied with the medication.I confirm the documents/photos uploaded are my own and are true and accurate.I consent to the practice securely storing this information in line with our data protection policy and clinical record‑keeping.
Should be Empty:

Mounjaro (tirzepatide) Pre‑Clinical Consultation for Kepple Lane Pharmacy

Section A - Patient Details

Section B: Identity & Weight Verification

We’ll schedule a short video call to confirm the scale reading

Section C- Eligibility Screening

Section D — Medical History (tick all that apply)

Section E — Diabetes Medications

Section F — Other Medications & Allergies

Section G — Lifestyle

Section H — Upload recent blood test results (optional but recommended)

Section I — Patient Education & Consent