Do you experience any of the following symptoms?

Chest pain or shortness of breath when walking four blocksChest pain or shortness of breath when having sexUnexplained dizzinessCramping of legs with exerciseAbnormal heart beats that prevent you from exerciseNone of the above

Do you have a history of hypothyroidism (low thyroid)?

YesNever had a problem with hypothyroidism

Do you currently drink alcohol or alcoholic beverages?

Drink more than one drink/day (women only)Drink more than two drinks/day (men only)More than five drinks at one time for five days in a row

Are you allergic to any medicines? Milk protein? Aspirin, NSAIDs, or phenylalanine?

YesNo

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

Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

YesNo

Do you have any of these conditions?

Seizure disorder or epilepsyGlaucoma, cataracts, or high intraocular pressureOsteoporosisHistory or currently have tuberculosis (TB)Myasthenia gravisSclerodermaCancer or history of cancerMigraine headachesNone apply

Anything else you would like us to know?

YesNo

How would you like to pay?

Out of pocketInsuranceupload emirates insurance details (if available)

Upload a Photo of your Emirates ID
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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:
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.