What is your date of birth?

Enter your most recent blood pressure reading from the previous six months

The 2nd number is the lowest

Do you remember when you took this blood pressure reading?

YesNo

Select how your reading was done

By a healthcare professionalTest done at home

Have you taken a hypertensive medicine before?

YesNoWhat is the drug's name?

Do you know what your heart rate is?

YesNo

What's your weight (in kilograms)?

What's your height (cm)?

Select all that apply to you

Pregnant or trying to become pregnantBreastfeedingKidney problems including having had a kidney transplantLiver problems or history of liver problemsSeizure disorder or epilepsyNone apply

Have you ever taken blood thinners or medicines to regulate your heart rhythm before?

YesNo

Do you have any of the following symptoms?

Chest pain with physical activityShortness of breath with physical activityChest pain with sexShortness of breath with sexUnexplained dizzinessFaintingCramping of legs with exerciseAbnormal heart beats that prevent you from exerciseNone of the above

Can you do at least 150 minutes of moderate physical activity per week?

YesNo

Have you ever been diagnosed with any of the following medical problems?

Sleep apneaHeart murmurCongestive heart failure (CHF)History or family history of QT prolongationHeart arrhythmia / Atrial fibrillationHeart valve problemsHypertrophic obstructive cardiomyopathy (HCM)Pacemaker and/or defibrillatorAblationPrimary aldosteronismPheochromocytomaCoarctation of the aortaCushing's SyndromeNone apply

Do you have any of the following medical conditions?

Hypothyroidism (low thyroid)Heartburn or GERDDepressionAnxietyADHD (Attention Deficit/Hyperactivity Disorder)BPH (enlarged prostate)AsthmaEmphysema or COPDMigraine headachesNeurologic problems including Parkinson's, multiple sclerosisImmune system problemsHIVGenital HerpesCold SoresOther

Select all that apply to you

Smoking cigarettesDrinking alcoholDrinking caffeine (coffee, tea, or cola)Quit smokingUse of recreational drugsNone apply

Are you allergic to any medicines?

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

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 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.