I agree that the pharmacist may contact my GP practice to confirm my medical history to ensure that it is suitable for me to receive weight loss treatment. (Note agreement for gp contact is a condition for supply.)*

Acknowledgement 1:

I agree the pharmacy staff can check my height and weight and nwhere appropriate phot evidence may be asked to be uploaded using the photo evidence form.*

Acknowledgement 2:

I understand I should use one weight loss product at any one time*

Acknowledgement 3:

I understand the safest and most effective weight loss outcomes are achieved by slowly increasing dose to gain the maximum benefit from the lowest dose possible. I understand that if I have a gap in treatment longer than 2 weeks, I may need to reduce my dose to avoid side effects.*

Acknowledgement 4:

I understand that Wegovy/Mounjaro is an under the skin injection. I will not inject it into a vein or muscle. The best places to give the injection are the upper arms, stomach or upper legs. I will ensure to drink plenty of fluids to avoid dehydration. Detailed instructions will be found in the patient leaflet.*

Acknowledgement 5:

I understand that I will stop treatment and inform the pharmacy and/or seek medical attention if I experience severe dehydration, e.g. dark urine, confusion, blood in stool or vomit, diarrhoea lasting longer than 72 hours, or being unable to keep food down without vomiting/diarrhoea.*

Acknowledgment 6:

I understand that if I experience any side effects from treatments, I can contact the pharmacy Pharmacy, my GP, or another healthcare professional for advice. I confirm that I will read about the side effects in the Patient Information Leaflet*

Acknowledment 7:

I confirm that all the above information is truthful and accurate. I agree to inform the pharmacy of any changes to my health as soon as possible, as I understand this could impact the suitability of the medication I am being prescribed.*

Side effect 1:

Aspiration during anesthesia. Patients MUST inform health teams and anesthetists they are taking a glp-1 and or GIP agonist*

Side effect 2:

Contraception. For month one after initiation and dose changes, females of a reproductive age, need to use barrier method in addition to oral contraception*

Side effect 3:

Low blood sugar. Your risk for getting low blood sugar may be higher if you use a GLP1 with another medicine that can cause low blood sugar, such as a sulfonylurea or insulin. *

Side effect 4:

Dehydration. Diarrhoea, nausea, and vomiting may cause a loss of fluids (dehydration) which may cause kidney problems. It is important for you to drink fluids to help reduce your chance of dehydration.*

Side effect 5:

Stomach problems. Stomach problems, sometimes severe, have been reported in people. Tell your healthcare provider if you have stomach problems that are severe or will not go away.*

Side effect 6:

Changes in vision.Tell your healthcare provider if you have changes in vision during treatment*

Side effect 7:

Gallbladder problems. pain in your upper stomach (abdomen), fever, yellowing of skin or eyes (jaundice), clay-coloured stools*

Side effect 8:

Most common side effects nausea

• diarrhoea

• decreased appetite

• vomiting

• constipation

• indigestion

• stomach (abdominal) pain

*

Side effect 9:

Inflammation of your pancreas (pancreatitis):

Stop using MOUNJARO and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back*