Wegovy® — Pre-Prescribing Assessment & Consent | Ph. Health Studios Derby
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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.

GLP-1 Receptor Agonist (semaglutide) · Novo Nordisk · POM ▼

Wegovy® (Semaglutide)

FlexTouch® — pre-filled pen · 0.25mg / 0.5mg / 1mg / 1.7mg / 2.4mg
0.25mgStarting dose
Once weeklyFrequency
2.4mgMaintenance dose
≥27 BMIMinimum BMI (with comorbidity)
Licensed UK indication (SmPC via EMC, May 2026): Weight management in adults with BMI ≥30 kg/m², or BMI 27–<30 kg/m² with at least one weight-related comorbidity. Cardiovascular risk reduction in adults with established CVD and BMI ≥27. Weight management in adolescents aged ≥12 years with obesity (BMI ≥95th percentile) and body weight >60kg. 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 semaglutide or excipientsKnown hypersensitivity to semaglutide or any excipient in Wegovy FlexTouch pen.If YES — do not prescribe. Document and explore alternatives.
Present?
Pregnancy or planning pregnancy within 1 monthSemaglutide must not be used during pregnancy (animal reproductive toxicity shown). Discontinue at least 2 months before planned pregnancy due to long half-life (~1 week). Not recommended during breastfeeding.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. Wegovy 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)Semaglutide 2.4mg is not anticipated to reduce oral contraceptive efficacy — no clinically relevant effect on ethinylestradiol/levonorgestrel exposure at steady state. However, co-administration with another GLP-1 receptor agonist is contraindicated.Standard contraception counselling. No additional barrier method required for OC users per SmPC. Document advice.
Present?
Narrow therapeutic index medications (warfarin, digoxin, others)Semaglutide has minimal effect on gastric emptying at 2.4mg steady state — clinically relevant drug interactions not identified. However, cases of decreased INR with acenocoumarol/warfarin reported. Monitor INR on initiation with warfarin.Monitor INR if patient on warfarin. Document.
Present?
Severe renal impairment (eGFR <30) or end-stage renal diseaseNo dose adjustment required (not recommended in end-stage renal disease). GI-induced dehydration may worsen renal function. Limited experience in severe renal impairment.Use with caution. Counsel on hydration. Monitor renal function.
Present?
Severe hepatic impairmentLimited experience with semaglutide in severe hepatic impairment. Dehydration from GI effects may worsen hepatic function.Use with caution. Monitor carefully. Document.
Present?
Non-arteritic anterior ischaemic optic neuropathy (NAION) — history or riskEpidemiological data suggest a possible ~2-fold increase in relative risk of NAION with semaglutide treatment. Patients with sudden partial or total vision loss must be urgently referred for ophthalmological assessment. Discontinue Wegovy if NAION confirmed.Counsel on reporting any sudden visual changes immediately. If known NAION history — document risk discussion. Discontinue immediately if NAION suspected.
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.

Wegovy® dose escalation schedule — UK SmPC (Adults, May 2026)

Weeks
Dose
Notes
1–4
0.25 mg
Standard starting dose. SubQ: abdomen, thigh or upper arm. Not IM or IV.
5–8
0.5 mg
Minimum 4 weeks at 0.25mg before escalation. Delay if significant GI symptoms.
9–12
1 mg
Continue escalation if tolerated
13–16
1.7 mg
Penultimate escalation step
17+
2.4 mg
Maintenance dose (all indications). If <5% weight loss at 6 months — reassess benefit/risk.
Optional
7.2 mg
Adults with obesity only. Min 4 weeks on 2.4mg. Not recommended for adolescents.
✅

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 Wegovy and do not restart if pancreatitis confirmed.
Done
Missed dose guidance givenTake as soon as possible within 5 days of missed dose. If >5 days — skip and resume on scheduled day. Do not double dose. If multiple doses missed, consider reducing dose on re-initiation. Day can be changed if ≥3 days since last dose.
Done
Contraception & pregnancy counselledNot for use in pregnancy or breastfeeding. Effective contraception required throughout. Semaglutide 2.4mg not anticipated to reduce OC efficacy — standard contraceptive counselling applies. Stop Wegovy ≥2 months before planned pregnancy due to long half-life.
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 Wegovy FlexTouch pen pack). Patient directed to read before first injection. Wegovy is subject to additional monitoring (▼ black triangle) — MHRA Yellow Card reporting discussed.
Done
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Prescribing record

Confirm starting dose and next review

Per SmPC: all adults commence at 0.25mg. 16-week escalation schedule to 2.4mg maintenance.
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

Wegovy® (semaglutide) 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 Wegovy®. 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 Wegovy® 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 Wegovy®. Semaglutide at the prescribed dose is not anticipated to reduce the effectiveness of oral contraceptives. However, effective contraception must be maintained throughout treatment. If you wish to become pregnant, Wegovy® must be stopped at least 2 months before attempting conception due to its long half-life. Wegovy® should not be used during breastfeeding. 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 Wegovy® 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

Wegovy® is subject to additional monitoring (▼ black triangle). If you experience a side effect, please 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; that you understand you may withdraw consent at any time; that you understand the risks and benefits of Wegovy® (semaglutide) treatment as explained during your consultation today; and that you accept the obligations set out 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) *
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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 Wegovy® (semaglutide) 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 Wegovy® (semaglutide) has been completed and recorded. Print or save this page for the patient clinical file.

Patient: —
Date: —
Wegovy® 0.25mg 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
Wegovy® is a registered trademark of Novo Nordisk A/S. SmPC sourced from EMC (medicines.org.uk), last updated May 2026. This form should be reviewed whenever the SmPC is updated.