Eligibility Check - Panmedica Pharmacy

Height

cm

Weight

Kg

BMI (Must be greater than 30 to be eligible for Mounjaro)

Are you between the ages of 18 and 65 and reside in the UK?

Yes

No

What is your first name?

We will contact you using this name.

And your last name?

Now, what is your date of birth?

What is your email address?

And your phone number?

Do you identify as South Asian, Black African or Caribbean, Chinese, or Middle Eastern

Yes

No

I agree to have a video consultation (required by GPhC for first time patients) and acknowledge I will not be able to receive my order before this.

Yes

No

Have you been diagnosed with diabetes? Certain medication can impact the way our weight loss treatments work

Yes

No

Do you take GLP-1 receptor agonists? These commonly include Mounjaro, Ozempic, Wegovy, Saxenda, Victoza, Rybelsus, Trulicity and Bydureon.

Yes

No

Do you have any known allergies?

Yes

No

Please provide additional information about your medical history including other medications (prescribed, over the counter or herbal) and other medical conditions not mentioned previously.

Please attach evidence of your long-term medication if applicable. This can be a screenshot of your NHS app, a picture of your recent repeat prescription or picture of your medicine box with your name and date on it. (you can press NEXT if you have already provided us with one recently and there has not been any changes)

If you checked any boxes, please provide additional information

Do you agree and consent to the following: I am over 18 years old and live in the UK. I will be the sole user of any medication offered to me through this service. I confirm all answers are provided by me and are completely truthful.

Yes

No

I give my full consent to Panmedica Pharmacy to let my GP know that I am taking this treatment.

Yes

No

Please upload a copy of your ID This needs to include your name, picture and either a DOB/Address (you can upload a picture of multiple IDs to cover all 3 requirements) This is only required for your first order with us – you can skip otherwise

Maximum file size: 516MB

Please upload a recent full body image including your face. This will not be public and will only be visible to the prescriber.

Maximum file size: 516MB

Thanks! How would you prefer to be contacted?

Phone

Email

GDPR Consent

I consent to having this website store my submitted information so they can respond to my inquiry.

Weightloss Questionnaire