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—Please choose an option—Abu DhabiAl AinDubaiSharjahAjman
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Less than a yearBetween one & five yearsMore than 5 years
10 or less11 - 20 cigarettes21 - 30 cigarettes31 - 40 cigarettes41 or more
Less than five minutes5 to 30 minutes31 to 60 minutesLonger than 60 minutes
Pregnant or possibly pregnantBreastfeedingHeart problemsMental health conditionsSeizures or epilepsyHypertension / High Blood PressureKidney problemsLiver problemsHIVOtherNone apply
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.
Out of pocketInsurance upload emirates insurance details (if available) Upload a Photo of your Emirates ID Upload Front Upload Back
Google MapDelivery Location Google Map: (Please Share your Google Map Link) Delivery Location Neighborhood/Area: Street Name/No: Address Details:
Title: Mr.Ms. First Name: Last Name: 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.
