Medical Assessment Safe Medication Purchase for Insomnia Complete our form to ensure the safe and reliable purchase of medication for insomnia. Your health and privacy are our top priorities. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 4About YouFull Name *FirstLastDate of Birth *Email *NextYour HealthDo you have a history of chronic insomnia? *YesNoWe are unable to supply Zopiclone without a history of chronic insomnia. Please consult your GP or doctor for appropriate treatment. How long have you been experiencing sleep difficulties? *Less than 1 month1-3 monthsOver 3 monthsWe are unable to supply Zopiclone for short-term sleep difficulties. Please consult your GP or doctor for further advice. Do you have any history of respiratory issues, such as sleep apnea? *YesNoWe are unable to supply Zopiclone for patients with a history of respiratory issues such as sleep apnea. Please consult your GP or doctor. Do you have a history of substance misuse, including alcohol or drugs? *YesNoWe are unable to supply Zopiclone due to a history of substance misuse. Please consult your GP or doctor for alternative treatments. Are you currently pregnant, planning to become pregnant, or breastfeeding? *YesNoWe are unable to supply Zopiclone during pregnancy or while breastfeeding. Please consult your GP or doctor for alternative treatments. Do you suffer from any mental health conditions, such as depression or anxiety? *YesNoWe are unable to supply Zopiclone for patients with certain mental health conditions. Please consult your GP or doctor. Do you have any known allergies to medications? *YesNo Penicillin or other antibiotics Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, aspirin Sulfonamides (sulfa drugs) Chemotherapy drugs Anticonvulsants (e.g., carbamazepine, phenytoin) Local anesthetics (e.g., lidocaine, procaine) Vaccines or biologics We are unable to supply Zopiclone due to your reported allergy. Please consult your GP or doctor. NextYour MedicationHave you previously been prescribed Zopiclone or any other sleep medication? *YesNoPlease specify the medication and dosage *Are you currently taking any other medications? *YesNo Opioid medications (e.g., morphine, codeine) Antidepressants (e.g., SSRIs, MAO inhibitors) Antipsychotics (e.g., clozapine, quetiapine) Other sedative medications (e.g., benzodiazepines, barbiturates) Antihistamines (especially first-generation antihistamines like diphenhydramine) Muscle relaxants (e.g., baclofen, tizanidine) Medications for anxiety or panic disorders (e.g., diazepam, lorazepam) We are unable to supply Zopiclone due to potential interactions with your current medications. Please consult your GP or doctor. NextAgreementDo you understand that the information you have provided is accurate and truthful to the best of your knowledge? *YesNo You must agree to this before continuing. If you need assistance, please contact our customer support. Do you understand that your order will be reviewed by a qualified healthcare professional and that the medication will only be supplied if deemed appropriate based on the information you have provided? *YesNo You must agree to this before continuing. If you need assistance, please contact our customer support. Do you understand the treatment should be taken with a nutritionally balanced, calorie-controlled diet that contains approximately 30% of the calories from fat? It is recommended that your diet is rich in fruit and vegetables. *YesNo You must agree to this before continuing. If you need assistance, please contact our customer support. Do you agree to the following? *YesNo You will read the patient information leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, you start new medication and/or your medical conditions change during treatment The treatment is solely for your own use You have answered all the above questions accurately and truthfully You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber You must agree to this before continuing. If you need assistance, please contact our customer support. I agree to the Terms & Conditions and Privacy Policy *I agreePlease read these Terms and Conditions carefully before using our website drugs4delivery.com, associated applications, and services operated by Drugs4Delivery. 1. Acceptance of Terms By accessing and using our services, you agree to be bound by these Terms and Conditions, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. If you do not agree with any of these terms, you are prohibited from using or accessing this site. 2. Privacy Your privacy is very important to us. Our Privacy Policy, which also governs your visit to our site, can help you understand how we collect and use your personal information. Please read it here: Privacy Policy. 3. Use License Permission is granted to temporarily download one copy of the materials (information or software) on Drugs4Delivery’s website for personal, non-commercial transitory viewing only. This is the grant of a license, not a transfer of title, and under this license, you may not: Modify or copy the materials; Use the materials for any commercial purpose, or for any public display (commercial or non-commercial); Attempt to decompile or reverse engineer any software contained on Drugs4Delivery’s website; Remove any copyright or other proprietary notations from the materials; or Transfer the materials to another person or “mirror” the materials on any other server. 4. Disclaimer The materials on Drugs4Delivery’s website are provided on an ‘as is’ basis. Drugs4Delivery makes no warranties, expressed or implied, and hereby disclaims and negates all other warranties including, without limitation, implied warranties or conditions of merchantability, fitness for a particular purpose, or non-infringement of intellectual property or other violation of rights. 5. 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The inclusion of any link does not imply endorsement by Drugs4Delivery of the site. Use of any such linked website is at the user’s own risk. 8. Modifications Drugs4Delivery may revise these terms of service for its website at any time without notice. By using this website, you are agreeing to be bound by the current version of these Terms and Conditions. 9. Governing Law These terms and conditions are governed by and construed in accordance with the laws of [Jurisdiction] and you irrevocably submit to the exclusive jurisdiction of the courts in that location. 10. Contact Us If you have any questions or concerns about these Terms and Conditions, please contact us by e‑mail at info@drugs4delivery.com or phone at 01472 241990. We are committed to protecting and respecting your privacy. This Privacy Policy outlines how we handle, store, and protect your personal data when you use our website drugs4delivery.com, associated applications, and services. Information We Collect We may collect and process the following data about you: Personal Information: Your name, address, email address, telephone number, and other contact details. Health Information: Prescription details, medical history, and other health-related information necessary for us to provide you with our services. Transaction Data: Details about payments to and from you and other details of products and services you have purchased from us. Technical Data: Internet protocol (IP) address, your login data, browser type and version, time zone setting and location, browser plug-in types and versions, operating system and platform, and other technology on the devices you use to access this website. Usage Data: Information about how you use our website, products, and services. How We Use Your Information We use information held about you in the following ways: To Fulfil Our Services: To dispense and deliver prescriptions and other products. To Communicate With You: Responding to your inquiries, providing information about changes to our services, and handling customer service interactions. For Legal Obligations: Complying with regulatory and legal obligations. For Marketing Purposes: Providing you with promotional materials or communications regarding products and services that may be of interest to you, where you have consented to be contacted for such purposes. Data Protection We take the security of your data seriously. We have implemented appropriate technical and organizational measures to protect your personal data against unauthorized or unlawful processing, accidental loss, destruction, or damage. Sharing Your Information Service Providers: We may employ third-party companies and individuals to facilitate our service (e.g., payment processors, technology service providers). Legal Requirements: We may disclose your information where required by law or subpoena. 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Contact Us If you have any questions about this Privacy Policy or our privacy practices, please contact us by e‑mail at info@drugs4delivery.com or phone at 01472 241990.Submit