Jet Lag Prescription

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Do you agree and consent to the following?

You are completing this consultation for yourself and to the best of your knowledge.
You will disclose any medical conditions, serious illnesses or operations you have had.
You will disclose any prescription medications you are currently taking and agree to use only one weight loss treatment at a time.
You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy.
Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life-threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation.
You agree to undergo identification and age verification. This may require submitting valid documents to our approved third-party verification partner for validation.
You consent to EveryDayMeds accessing your Summary Care Record (SCR) for the purpose of ensuring the safe supply of treatment. If the SCR is unavailable or incomplete, you agree to participate in appropriate two-way communication (e.g. phone, secure message, or video consultation) to verify your medical history. If you do not respond or engage, your order will be cancelled.

Your Health

Are you aged between 18 and 75?

Yes No

Are you using this medication specifically for the treatment of jet lag?

Yes No

Are you currently pregnant, breastfeeding, or possibly pregnant?

Yes No

Medical Condition

Do you have an allergy to lactose or melatonin?

Yes No

Do you currently have or have ever had any of the following conditions?

Kidney problems
Liver problems
Heart problems
Autoimmune conditions (e.g. Rheumatoid arthritis, Graves’ disease)
Galactose intolerance or glucose-galactose malabsorption
Alcohol dependency
Depression treated with medication
Schizophrenia or bipolar disorder
Epilepsy or history of seizures

Yes No

Medication

Are you currently taking any medication (prescribed, over-the-counter or recreational)?

Yes No

Are you taking any of the following medications?

Benzodiazepines (e.g. diazepam, lorazepam)
Sleeping tablets (e.g. zopiclone, zolpidem)
Fluvoxamine
Hormone replacement or contraceptive pills containing oestrogen
Blood thinners (e.g. warfarin)
Carbamazepine
Rifampicin, ciprofloxacin or other antibiotics
Teriflunomide, leflunomide
Axitinib or similar

Yes No

Do you understand the following?

Melatonin can enhance drowsiness and lower blood pressure when taken with certain medicines. If you are on any of the medications listed below and experience light-headedness, dizziness, or extreme sleepiness, you must stop taking Melatonin and seek medical advice:

Alcohol
Alpha-blockers (e.g. Doxazocin, Alfuzosin, Tamsulosin, Prazocin)
Tricyclic antidepressants
Antihistamines
Antipsychotics
Myelosuppressive drugs
Baclofen
Beta-blockers
Calcium-channel blockers
Clonidine
Diazoxide
Diuretics
Guanfacine
Hydralazine
Lofexidine
Methyldopa
Minoxidil
Mirtazapine
Moxonidine
Nitrates
Opioid analgesics
Phenobarbital
Primidone
Ritonavir
Sodium nitroprusside
Tizanidine

Yes No

Agreement

Do you agree to the following?

You will read the patient leaflet provided with your medication
You will contact your GP if you develop side effects or start new medication
This treatment is for your own use only
You have answered truthfully
You understand that clinical decisions rely on the accuracy of your answers
The final decision to issue a prescription rests with the prescriber

Yes No

Do you understand that Melatonin can cause drowsiness and should not be taken before driving or operating machinery (within 8 hours)?

Yes No

Do you understand Melatonin should be taken at your bedtime in the new time zone (between 8pm–4am) and only for a maximum of 5 days?

Yes No

Do you understand that Melatonin may increase risks such as drowsiness, memory issues, falls, and dependence?

Yes No

Do you understand that Melatonin should not be taken with alcohol?

Yes No

Do you give us permission to access your NHS Summary Care Record or request medical history from your GP if required?

Yes No

Do you consent to us sharing relevant consultation details with your GP to ensure continuity of care?

Yes No

GP Consultation

We can notify your GP of your treatment for you. To do so, we need their contact information. Sharing this information allows your GP to maintain a comprehensive record of your medical history, which is crucial for your health. Without complete records, there could be potential risks to your well-being.

I consent to EveryDayMeds contacting my GP and share information about my prescription.

Yes No

Practice/GP Name

Practice/GP Address

Identity Verification

Please upload your identification documents.

Would you like to upload documents now?

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What you need to upload

To safely prescribe weight-loss medication, our clinicians need to verify your identity and assess your eligibility. Please upload both of the following:

Photo ID

Upload a clear photo of one valid ID document, such as:

Passport
UK driving licence
National ID card

Requirements:

The full document must be visible
Text and photo must be clear and readable
The ID must be valid (not expired)

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Tap to upload ID card

No file chosen

Full-Body Photo

Take a full-body photo of yourself using your camera.

Photo guidelines:

Full body visible (head to feet)
Wear fitted clothing (no coats or baggy clothes)
Stand straight, facing the camera
No filters or edits

This photo is used only to help our clinicians assess your BMI and suitability for treatment.

📸

Take photo using camera

Camera required

Upload Previous Prescription

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Upload previous prescription

No file chosen

If you select this option, your order won’t be approved until all required documents are submitted. After your consultation, we’ll email you instructions on how to upload your documents.

Your Jet Lag Prescription Plan

Melatonin 3mg Tablets

£14.99

Quantity

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