What is your date of birth?

Which symptoms do you experience? select all that apply to you

Burning sensation in the back of your throatBitter, acid taste in your mouthUncomfortable feeling from your stomach to your mouth or to the back of your throatOther

When do you experience acid reflux symptoms? Select all that apply to you

After mealsAt the nightWhen laying down shortly after eatingOther

What triggers your Acid reflux symptoms? Select all that apply to you

Drinking coffeeEating fatty or spicy foodsSmokingPregnancyFeeling stress and anxietyOtherNone Tell us more

How often have you had acid reflux symptoms?

Once a weekTwice a weekMore than half of the daysEvery dayOther Tell us more

Have you ever taken any over-the-counter (OTC) antacids or heartburn medicines for these symptoms?

YesNoAre you allergic to any medicine? YesNo Please list your drug allergies and what happens when you use that drug.

Do you find that antacids only provide temporary relief from your symptoms?

YesNo

Do you take other medication(s) or have any other medical conditions?

Please include any antibiotics, name of birth control, as well as any over-the-counter and herbal dietary or potassium supplements.

YesNoIn order for us to provide you with the best care, please let us know what medications you take and what conditions you have.

Do you have any of these conditions?.

NonePregnant or planning to become pregnantBreastfeedingHistory of kidney problemsHistory of liver problemsA diagnosed immune disorderOther

Anything else you would like us to know?

YesNo

How would you like to pay?

Out of pocketInsurance upload emirates insurance details (if available) Upload a Photo of your Emirates ID Upload Front Upload Back

Billing and delivery details

Google MapDelivery Location Google Map: (Please Share your Google Map Link) Delivery Location Neighborhood/Area: Street Name/No: Address Details:

Personal Details

Title: Mr.Ms. First Name: Last Name: Date of Birth: Mobile Number: E-mail:

Confirm Request and Agree to Terms

After you submit your request, a licensed medical provider will review your information. You will be notified by email/contact number when that provider has reviewed your request and, if appropriate, made care recommendations.