What is your date of birth?

Have you been diagnosed with migraine headaches by a doctor in person?

YesNo

Have you noticed any change in the location, type of pain, intensity or frequency of your headaches since your last visit with your doctor or over the last 1 year?

YesNo

Which type of treatment plans are you interested in?

Taking medications as needed, when I get migraine headachesTaking medications to prevent migraine headaches.Other

Did you experience any side effects with previous headache treatments that would stop you from using them again?

No, never taken any medicines beforeNo, never had side effects that bothered meYes

How often do you take medicine to treat headaches in a week?

Less than once a weekOnce a weekTwice a weekThree or more times a weekI do not take headache medicine

How many times a MONTH do you get a headache?

Less than once a monthOnce a monthTwice a monthThree times a monthFour or more times a monthDon't know. I'm taking medicine regularly to prevent headaches

Which side of the head are your headaches typically located? Select the one option that best applies to you.

Left side of the headRight side of the headOne side and other times the other sideBoth sides togetherOther

WHERE on the head are your headaches located?

Top of the headAcross the foreheadLeft templeRight templeLeft eyeRight eyeNeckOther

What does your headache pain feel like?

PulsatingThrobbingStabbingAchingSharpDullPressureTighteningOther

How soon do your headaches reach maximum intensity?

A few seconds (less than 1 minute)A few minutes (less than 1 hour)1 hour or longerOther

Without medicine, how long do your headaches usually last?

0 to 4 hours4 to 12 hours12 to 24 hours (less than 1 day)24 to 72 hours (1-3 days)More than 72 hoursOther

Do you have an AURA with your headaches? (Change in vision lasting 5-60 minutes, occurs with headache, or followed by a headache within 1 hour. These can be tiny area of visual loss, seeing bright spots, geometric shapes, zigzagging lines, shooting stars)

YesNo

Which of the following symptoms do you get with your headaches? Select all that apply to you.

NauseaVomitingSensitivity or avoidance of loud soundsSensitivity or avoidance of bright lightsNone apply

Do you have any drug allergies?

YesNo

Are you taking any other medicines?

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

Anything else you would like us to know?

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

Insurance Card Image (Optiona

Insurance provider: Insurance card no: Upload Insurance card: Feel free to leave any additional comments here:

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.