ZapMeds

About you

What was your sex at birth?*

Are you between 18-74 years old?*

Do any of the following racial or ethnic groups make up at least half of your genetic heritage?*

What's your height?*

cm

What's your weight?*

kg

Medical history

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

It’s important you tell us about your medical history to help us provide safe and effective treatment recommendations. - Liver cirrhosis or a liver transplant - 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) - Treatment or rehabilitation for excessive alcohol use - Chronic malabsorption syndrome - An endocrine disorder (overactive thyroid awaiting radioactive iodine or surgery, acromegaly, Addison’s disease, Cushing’s syndrome, congenital adrenal hyperplasia, growth hormone disorder) - Any cognitive or memory impairment, such as dementia

Do you currently have or have you ever had any of the following gut problems?*

• Gallstones or gallbladder problems • Crohn's disease or ulcerative colitis • Pancreatitis • Gastroparesis • Blocked bile flow (cholelithiasis) • Gallbladder surgery in the past 12 months

Have you had bariatric weight-loss surgery or a gastric band procedure (either placement or removal) within the past 12 months?*

This includes: - Sleeve gastrectomy (gastric sleeve) - Gastric bypass (Roux-en-Y) - Gastric balloon - Endoscopic sleeve gastroplasty - Biliopancreatic diversion or duodenal bypass

Have you ever had an eating disorder, for example, anorexia or bulimia nervosa?*

If you think you may have an eating disorder, but have never been diagnosed, please choose ‘yes’.

Have you ever experienced an allergic reaction to Wegovy, Ozempic, Mounjaro, Saxenda, or Victoza?*

Have you been diagnosed with type 1 diabetes?*

If you have type 2 diabetes, are you using insulin?*

If you have type 2 diabetes, are you taking any medication (other than metformin and insulin) to manage your blood sugar?*

Do you have a personal or family history of medullary thyroid cancer, thyroid cancer, or MEN2 syndrome?*

Do you have any other medical conditions that we haven't asked about yet?*

Your medication

Are you currently taking any of the following medications?*

It's important you tell us about any of these medications to help us provide safe and effective treatment recommendations. - Amiodarone - Carbamazepine - Ciclosporin - Clozapine - Digoxin - Fenfluramine - Lithium - Mycophenolate mofetil - Oral methotrexate - Phenobarbital - Phenytoin - Somatrogon - Tacrolimus - Theophylline - Warfarin

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

This can be with ZapMeds or another provider.

Are you taking any medications to treat your thyroid?*

Do you use any other medication?*

This includes anything prescribed or bought over the counter or online, such as creams/ointments, vitamins or supplements, eye drops, gels, inhalers, or the contraceptive pill.

Consent

Please check that you understand and agree to this information:*

• If you are sexually active, note that Mounjaro® may reduce the effectiveness of the oral contraceptive pill. • You’ll need to use other forms of contraception (such as condoms or an IUD/implant) while taking Mounjaro® to prevent unplanned pregnancy.

I understand and agree

Please check that you understand and agree to this information:*

• The information I have provided is true and accurate to the best of my knowledge. • The information I have provided will be used by the prescribers to decide whether it is appropriate to supply medication. • I understand that failure to give accurate information may result in a refusal to supply medication, or the supply of medication that is not suitable. • I understand that rapid weight loss and injectable weight loss treatments like Mounjaro® and Wegovy® can both raise the risk of pancreatitis and gallbladder issues. If I have severe abdominal pain, vomiting, jaundice (yellowing of the skin), or worsening symptoms, I will seek urgent medical help. • I understand that severe diarrhoea for over 24 hours, or vomiting within 3 hours of taking the contraceptive pill, can reduce its effectiveness. If this happens, I will call my GP or 111 for advice. I understand I may need a repeat dose of the contraceptive pill or to use additional contraception. • I understand that injectable weight loss treatments like Mounjaro® and Wegovy® should not be combined with other weight loss medications. • I recognise that these treatments may affect my mood. If I experience low mood or any mental health issues, I will stop the treatment and consult a doctor immediately.

I understand and agree

Please check that you understand and agree to this information:*

• The treatment is solely for my own use and I understand that I cannot supply medication prescribed for me to anyone else. • I will read the patient information leaflet supplied with the medication. • I will contact ZapMeds and inform my GP if I experience any side effects from treatment, begin any new medication, or if my medical conditions change during the course of treatment. • I agree to ZapMeds notifying my GP that I am taking GLP-1 weight loss medication and to allow my GP to share information with ZapMeds if they have any concerns. • I give my permission for ZapMeds to request further medical information from my GP if necessary.

I understand and agree

I agree to the Terms and Privacy Policy.

Health Screening

About you

Medical history

Your medication

Consent