Consent Form for Mounjaro Weight Loss (Strictly Confidential)

Name ______________________________________
Address ______________________________________
______________________________________________________
______________________________________________________
Post code ____________________
Telephone mobile ______________________________________
Email ___________________________________________
How may we contact you? _________________________________
Date of Birth ___________________________
Occupation ___________________________

Medical History Mounjaro
Do you have or have you ever suffered from any of the following conditions? If yes, please give details.
Heart Disease Yes/No

High Blood Pressure Yes/No

Hepatitis Yes/No

Psychiatric disorders Yes/No

Depression Yes/No

Diabetes/hypoglycaemia Yes/No

Blood Clotting Disorders Yes/No

Bleeding Disorders Yes/No

Neuromuscular disease Yes/No

Have you ever suffered from Pancreatitis Yes/No

Have you or anyone in your family had
Thyroid Cancer? Yes/No

Have you ever had or do you suffer from
Any form of cancer Yes/No

Do you have any Kidney problems Yes/No

Do you have a history of inflammatory
bowel disease such as colitis, Crohn’s,
coeliac disease or paralysis of the stomach Yes/No

Do you have any allergies or
hypersensitivities? Yes/No

Do you smoke? Yes/No

Do you have a history of an eating disorder? Yes/No

What is your average weekly alcohol consumption
________________________________________

Are you or have you been on any weight
loss medication? Yes/No

Have you had gastric surgery for weight loss? Yes/No

Are you pregnant or trying to conceive? Yes/No

Are you breast feeding? Yes/No

Are you on any oral contraception? Yes/No

Important – Please list all the medications you are taking

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Possible side effects of Mounjaro

Common
Nausea, diarrhoea, constipation.

Rare Mounjaro
Pancreatitis, kidney, gallbladder, hypoglycaemia, stomach or intestinal problems, liver and heart problems.
I have been fully informed by Dr Peter Lawson of the risks and possible side effects involved in the above treatment. The information I have given is to the best of my knowledge correct. I have not withheld any medical information. I will contact Dr Peter Lawson if I have any queries about my treatment. I understand that there is a medical aspect to the treatment being provided. I hereby consent to the treatment.

Date __________________

Patients Signature ________________________________