Choose your Location

—Please choose an option—Abu DhabiAl AinDubaiSharjahAjman

What is your date of birth?

What is (are) your complaint?

Can’t fall asleep easily.You wake up Several times at night and can't go back to sleepDon't feel refreshed when you awakenWaking with muscle or joint stiffness and achesWake up very earlyOther

Apply all you have

Your legs muscles cramp frequently.Kicking in your sleep.Your legs go limp when you are angry.You feel paralysed in the morning.Get morning headaches.Wake up gasping for air.Have been told that you snore.None of these apply

Do you often change your sleep schedule for work?

YesNo

Do you have trouble maintaining a consistent sleep schedule?

YesNo

On most days, how long does it take you to fall asleep?

0 - 30 minutes31 - 60 minutesMore than 1 hour

How many nights a week do you have a problem with your sleep?

0 to 1 night2 nights3 nights4 nights5 to 7 nights

How would you rate your sleep quality?

Very goodGoodAveragePoorVery poor

To what extent did poor sleep affect your work?

Not at allA littleSomewhatMuchVery much

How long have you had a problem with your sleep?

Less than one month1 to 2 months3 to 6 months7 to 12 monthsLonger than a year

Do you feel sleepy during the day?

AlwaysSometimesOftenRarelyNever

When you doze off during the day?

SittingWatching TVLying down to rest in the afternoonDuring social eventsOther

Do you dream vividly?

YesNo

Do you often feel sad or depressed?

YesNo

Do you want to tell us anything else?

YesNo

Are you allergic to any medicine?

YesNo

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

Please include any antibiotics, name of birth control, as well as any over-the-counter and herbal dietary or potassium supplements.

YesNo

Do you have any of these conditions?

NonePregnant or planning to become pregnantBreastfeedingHistory of kidney problemsHistory of liver problemsA diagnosed immune disorderOther

Anything else you would like us to know?

YesNo

How would you like to pay?

Out of pocketInsuranceupload emirates insurance details

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.