Mounjaro® — Pre-Prescribing Assessment & Consent | Ph. Health Studios Derby
1✓
Patient
Details
2✓
Eligibility
Check
3✓
Counselling
& Dosing
4✓
Consent
& T&Cs
5✓
Sign
& Submit
Step 1 of 5

Patient details & baseline assessment

Complete all fields. BMI is calculated automatically and eligibility checked against the licensed UK indication.

Dual GIP & GLP-1 Receptor Agonist · Eli Lilly · POM

Mounjaro® (Tirzepatide)

KwikPen® — multiple-dose pre-filled pen · 2.5mg / 5mg / 7.5mg / 10mg / 12.5mg / 15mg
2.5mgStarting dose
Once weeklyFrequency
15mgMaximum dose
≥27 BMIMinimum BMI (with comorbidity)
Licensed UK indication (SmPC via EMC, April 2026): Weight management in adults with BMI ≥30 kg/m², or BMI ≥27–<30 kg/m² with at least one weight-related comorbidity (hypertension, dyslipidaemia, OSA, CVD, prediabetes or T2DM). Also licensed for T2DM management as adjunct to diet and exercise. Not a substitute for diet and physical activity.
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BMI kg/m²
Clinical responsibility: This tool supports but does not replace clinical judgement. The independent prescribing pharmacist retains full responsibility for all prescribing decisions. Always verify against the current UK SmPC at medicines.org.uk.
Step 2 of 5

Contraindication & eligibility screening

Toggle ON if present. Any absolute contraindication will flag the patient as ineligible. Special warnings require documented clinical rationale.

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Absolute contraindications

SmPC §4.3 — prescribing contraindicated if any present

Not reviewed
Hypersensitivity to tirzepatide or excipientsKnown allergy to tirzepatide or any Mounjaro excipient, including benzyl alcohol (E1519). Note: benzyl alcohol 5.4mg per 0.6ml dose.If YES — do not prescribe. Document and explore alternatives.
Present?
Pregnancy or planning pregnancy within 1 monthTirzepatide must not be used during pregnancy (animal reproductive toxicity shown). Discontinue at least 1 month before planned pregnancy due to long half-life (~5 days).If YES — do not prescribe. Counsel on family planning and contraception.
Present?
Does not meet licensed BMI/indication criteriaBMI <27 kg/m² without T2DM, or BMI 27–30 without at least one qualifying weight-related comorbidity.If YES — outside licensed indication. Document clinical justification if proceeding off-label.
Present?
⛔ Prescribing contraindicatedOne or more absolute contraindications identified. Mounjaro must not be prescribed. Document in the clinical record and consider alternative management options.
⚠️

Special warnings & precautions

SmPC §4.4 — use with caution; document rationale and monitoring plan

Not reviewed
History of acute pancreatitisNot studied in this population. Post-marketing: necrotising pancreatitis and fatal outcomes reported. Counsel on symptoms (persistent severe abdominal pain). Discontinue if suspected; do not restart if confirmed.Use with caution. Counsel explicitly. Document.
Present?
Severe gastrointestinal disease / severe gastroparesisNot studied. GI adverse reactions (nausea, vomiting, diarrhoea) can cause dehydration and acute renal failure. Severe gastroparesis — consider contraindicated.Use with caution or avoid in severe gastroparesis. Counsel on hydration.
Present?
Diabetic retinopathy (non-proliferative requiring acute therapy, proliferative, or macular oedema)Not studied in this population. Use with caution and appropriate ophthalmological monitoring.Refer to ophthalmology if not already under review. Document monitoring plan.
Present?
Concomitant sulphonylurea or insulinIncreased risk of hypoglycaemia. Consider dose reduction of sulphonylurea or insulin at initiation. Blood glucose monitoring required.Discuss dose reduction plan. Document insulin/SU adjustment.
Present?
Oral contraceptives (combined or progestogen-only)Reduced Cmax of oral contraceptives at initiation and with each dose increase. Add barrier method for 4 weeks after initiation and 4 weeks after each dose escalation.Counsel explicitly. Consider switching to non-oral contraception. Document advice given.
Present?
Narrow therapeutic index medications (warfarin, digoxin, others)Delayed gastric emptying may affect absorption rate of co-administered oral medications, particularly at initiation and dose increases.Monitor INR/drug levels closely. Advise patient and GP. Document.
Present?
Severe renal impairment (eGFR <30) or end-stage renal diseaseNo dose adjustment required, but experience is limited. GI-induced dehydration may worsen renal function. Risk of benzyl alcohol accumulation in renal impairment.Use with caution. Counsel on hydration. Monitor renal function.
Present?
Severe hepatic impairmentLimited experience. Benzyl alcohol accumulation risk — inform patient. No dose adjustment required but caution warranted.Use with caution. Counsel on benzyl alcohol accumulation risk. Document.
Present?
Planned procedure under general anaesthesia or deep sedationCases of pulmonary aspiration reported in GLP-1 RA patients undergoing GA. Delayed gastric emptying increases risk of residual gastric content.Advise patient to inform surgical and anaesthetic teams. Consider temporary suspension pre-procedure.
Present?
⚠ Caution requiredOne or more special warnings apply. Document your clinical rationale, monitoring plan and counselling given before proceeding to prescribing.
Step 3 of 5

Counselling confirmation & dosing

Toggle ON to confirm each counselling point has been covered. Record planned starting dose and follow-up.

Mounjaro® dose escalation schedule — UK SmPC (Adults, April 2026)

Weeks
Dose
Notes
1–4
2.5 mg
Standard starting dose. SubQ: abdomen, thigh or upper arm. Rotate sites.
5–8
5 mg
Minimum 4 weeks at 2.5mg before escalation
9–12
7.5 mg
Continue if further reduction needed and tolerated
13–16
10 mg
Minimum 4 weeks at each dose before escalating
17–20
12.5 mg
Review benefit at each stage
21+
15 mg
Maximum dose. If <5% weight loss at 6 months on highest tolerated dose — reassess benefit/risk.
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Counselling points

Toggle ON to confirm each has been discussed with the patient

0/10 confirmed
Mechanism of action explainedDual GIP and GLP-1 receptor agonist. Reduces appetite, increases satiety, slows gastric emptying. Adjunct to — not replacement for — diet and exercise.
Done
Injection technique demonstratedKwikPen administration. Abdomen, thigh or upper arm. Rotate sites with each dose. Pen does not include needles — 4mm screw-on needles required separately. Sharps bin needed.
Done
GI side effects & hydration counselledNausea, vomiting, diarrhoea most common during dose escalation. Mostly mild-moderate, self-limiting. Importance of adequate fluid intake. Sick day rules if vomiting/diarrhoea.
Done
Pancreatitis warning givenPersistent severe abdominal pain → seek immediate medical attention. Stop Mounjaro and do not restart if pancreatitis confirmed.
Done
Missed dose guidance givenTake as soon as possible within 4 days of missed dose. If >4 days — skip and resume on scheduled day. Do not double dose. Day of administration can be changed if ≥3 days since last dose.
Done
Contraception & pregnancy counselledNot for use in pregnancy. Effective contraception required. Oral contraceptive users: add barrier method for 4 weeks at initiation and 4 weeks after each dose increase. Stop Mounjaro ≥1 month before planned pregnancy.
Done
Gallbladder risk discussedCholelithiasis and cholecystitis reported, especially with significant weight loss. Seek medical attention for right upper quadrant pain, fever or jaundice.
Done
Hair loss risk discussedReported in up to 4.9% of patients — mainly mild, most resolve with continued treatment. More common with greater weight loss. Not a reason to stop treatment.
Done
Monitoring and review plan agreedRegular weight and BP monitoring. 6-month review: if <5% weight loss at highest tolerated dose, reassess benefit/risk and consider stopping. Patient knows to contact clinic for side effects.
Done
Patient information leaflet providedPIL provided (included in Mounjaro KwikPen pack). Patient directed to read before first injection. MHRA Yellow Card reporting discussed (▼ additional monitoring).
Done
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Prescribing record

Confirm starting dose and next review

Per SmPC: all adults commence at 2.5mg. Minimum 4 weeks before first escalation.
Step 4 of 5

Terms, conditions & informed consent

Allow the patient time to read the following carefully. All three confirmations are required before proceeding to signature.

1. About this treatment

Mounjaro® (tirzepatide) is a prescription-only medicine (POM) licensed for weight management and/or blood sugar control. It is being prescribed by an Independent Prescribing Pharmacist at Ph. Health Studios Derby following a clinical assessment confirming suitability. It is an adjunct to — and not a substitute for — a healthy reduced-calorie diet and increased physical activity, which must be maintained throughout treatment.

2. Clinical responsibilities

This prescription is issued by Ph. Health Studios Derby, a private clinical service. Your GP has been or will be informed of this prescription by written summary. It is your responsibility to inform all other healthcare providers (including your GP, dentist, and hospital teams) that you are taking Mounjaro®. This is particularly important before any planned surgical procedures or when starting new medications.

3. Your obligations as a patient

  • Attend all agreed review appointments and monitoring visits.
  • Report any new symptoms, side effects, or changes in your health promptly.
  • Inform us immediately if you become pregnant or are planning a pregnancy.
  • Do not share this medication with any other person.
  • Do not obtain Mounjaro® from any other source while under our care without informing us.
  • Store medication correctly: refrigerate at 2–8°C. Once in use, may be kept at room temperature below 30°C for up to 21 days.
  • Dispose of used pens safely using a sharps bin.

4. Contraception requirement

If you are a person of childbearing potential, effective contraception must be used throughout treatment with Mounjaro®. If you take the oral contraceptive pill, you must use an additional barrier method (e.g. condoms) for 4 weeks when starting Mounjaro® and for 4 weeks after every dose increase, as Mounjaro® may reduce the effectiveness of oral contraceptives. If you wish to become pregnant, Mounjaro® must be stopped at least one month before attempting conception. Contact us immediately if pregnancy occurs.

5. Side effects — your duty to report

You have been counselled on side effects. Seek immediate medical attention (999/A&E) for: persistent severe abdominal pain (possible pancreatitis); severe allergic reaction including swelling of face, lips, tongue or throat, difficulty breathing; signs of serious hypoglycaemia if applicable. Contact Ph. Health Studios Derby during working hours for other side effect concerns.

6. Monitoring and review

Continued prescribing of Mounjaro® is conditional on regular review appointments. If you have been unable to lose at least 5% of your initial body weight after 6 months on the highest tolerated dose, the benefit/risk of continuing treatment will be reassessed in line with the UK SmPC. If you do not attend reviews, your prescription may be suspended pending a clinical review. Ph. Health Studios Derby reserves the right to discontinue prescribing if clinically indicated or if compliance with monitoring requirements is not maintained.

7. Limitations of private prescribing

This is a private prescription. The cost of medication is your responsibility. Ph. Health Studios Derby is not responsible for medication costs, availability at pharmacies, or any third-party supply issues. This service does not replace your NHS GP, and you should maintain your NHS registration and attend NHS appointments as normal.

8. Data and medical records

A full clinical record of this assessment and all subsequent interactions will be maintained in accordance with GPhC professional standards and UK GDPR. A clinical summary will be sent to your registered GP. Your data will not be shared with third parties without your consent, except where required by law or for your safety. You have the right to access your clinical records at any time.

9. Yellow Card reporting

Mounjaro® is subject to additional monitoring (▼ black triangle). If you experience a side effect, you are encouraged to report it via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk, in addition to reporting to us at Ph. Health Studios Derby.

10. Consent declaration

By agreeing and signing below, you confirm that: you have had the opportunity to ask questions and have received satisfactory answers; you understand that you may withdraw consent to treatment at any time; you understand the risks and benefits of treatment as explained during your consultation today; and you accept the obligations above.

Step 5 of 5

Signature & confirmation

Both a handwritten signature and typed name are required to complete this assessment.

Patient name

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Date of assessment

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BMI

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Starting dose

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Indication

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Prescriber

Zack — Independent Prescribing Pharmacist, Ph. Health Studios Derby

Patient handwritten signature (draw with finger or mouse) *
Sign here
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Full name typed (confirmation) *
Type your name exactly as it appears on official identification.
Date & time of consent
Declaration: By signing and typing your name above, you confirm that you have read, understood and agreed to the terms and conditions in Step 4, that you have had the opportunity to ask questions and are satisfied with the answers received, and that you consent to treatment with Mounjaro® (tirzepatide) being initiated by Ph. Health Studios Derby. This signed record will be retained as part of your clinical file in accordance with GPhC standards and UK GDPR.
✓

Assessment complete

Pre-prescribing assessment and patient consent for Mounjaro® (tirzepatide) has been completed and recorded. Print or save this page for the patient clinical file.

Patient: —
Date: —
Mounjaro® 2.5mg weekly
Ph. Health Studios Derby
Prescribing record: File in the patient's clinical record. Offer a copy to the patient. A clinical summary letter must be sent to the patient's GP within 24 hours of prescribing. Yellow Card reporting discussed.
Ph. Health Studios Derby  ·  phderby.com  ·  Independent Prescribing Pharmacist
Mounjaro® is a registered trademark of Eli Lilly and Company Ltd. SmPC sourced from EMC (medicines.org.uk), last updated April 2026. This form should be reviewed whenever the SmPC is updated.