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—Please choose an option—Abu DhabiAl AinDubaiSharjahAjman
The 2nd number is the lowest
By a healthcare professionalTest done at home
YesNoWhat is the drug's name?
What’s your heart rate
Pregnant or trying to become pregnantBreastfeedingKidney problems including having had a kidney transplantLiver problems or history of liver problemsSeizure disorder or epilepsyNone apply
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
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
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
Smoking cigarettesDrinking alcoholDrinking caffeine (coffee, tea, or cola)Quit smokingUse of recreational drugsNone apply
Average number of daily cigarett
How many cups a day?
Tell us more
Please list your drug allergies and what happens when you use that drug.
Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.
Please let us know what medications you take and what conditions you have.
Tell us about any concerns or questions you have for the medical team.
Out of pocketInsuranceupload emirates insurance details (if available)
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First Name: Last Name:
Date of Birth:
Mobile Number: E-mail:
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.