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Gender:
Date of birth
Why do you require this medication?
For further information kindly contact our patient support team:
0207 867 3932
email help@clickpharmacy.co.uk.
Do you suffer from any of the following?
Can you please provide more details?
Do you smoke and/or drink?
Are you pregnant or breastfeeding or may become pregnant or start breastfeeding whilst taking this medication?
Are you allergic to Melatonin or to any of its ingredients (such as lactose)?
Are you taking any of the following?
Please provide the name, dosage and the reason why you are taking that medication or medications
Are you taking any other medication not mentioned in the question above?
Do you understand and agree to the following?
Do you agree to the following?
Please tick the boxes to confirm the following:
Order before 15:00pm (Monday to Friday) for next day delivery
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