Assessment

Are you ordering Melatonin for Jet Lag?

Are you allergic to Melatonin? Melatonin is a hormone used in controlling sleep patterns.

Please confirm which country or countries you are travelling to, and/or from.

Have you ever been diagnosed with any of the following?

• Liver or Kidney condition,
• Epilepsy,
• An autoimmune condition (e.g. Rheumatoid Arthritis, Lupus)

• Diabetes or pre-diabetes

• Intolerance to any sugars (e.g. galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)

• Alcohol dependency

Are you taking any of the following:

• Fluvoxamine – used in depression and obsessive compulsive disorder (OCD)
• Oestrogens – found in birth control medication and hormone replacement therapies (HRT)
• Quinolone antibiotics (e.g. ciprofloxacin)
• Rifampicin – an antibiotic mostly used in tuberculosis
• Warfarin – a blood thinning medication
• Carbamazepine – used in epilepsy, trigeminal neuralgia and bipolar disorder
• Psoralen – used for severe psoriasis as part of PUVA treatment
• Any other sleep remedies

Please enter your date of birth

Please provide your gender (at birth)

Are you currently taking any other prescription-only medicines, alternative medicines or recreational drugs?

Please give more details below

Do you have any known allergies?

Please give more details below

Are you pregnant or planning to become pregnant or breastfeeding?

Do you have any other medical conditions?

Please provide more details below

We strongly advise that you inform your GP of any medication you receive.

Would you like us to inform your GP of medication you receive from Rightdose?

Please enter your:

• Full Name
• Date of Birth
• Your registered home address with your GP

Please enter your:

• GP Surgery Name
• GP Surgery Address
• GP Surgery Email
• GP Surgery Contact Number

I confirm:

• I am over 18 years old
• The medicine ordered is for my sole use only
• I take responsibility to inform my own regular doctor of the online assessment or any changes in my circumstances
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages
• I have answered all the questions truthfully
• I agree to the Rightdose online pharmacy privacy policy and terms and conditions

I confirm:

• I understand that melatonin can cause drowsiness. The use of alcohol and other medication that may cause drowsiness is to be avoided whilst taking melatonin
• I understand that melatonin should be taken once daily at the intended bedtime in the new time zone. It should only be taken between 8pm and 4am and should not be used for longer than 5 days

I understand that my request needs to be reviewed and approved by a prescriber. The request is not guaranteed until the prescriber approves it.