Pharma Aesthetics can only prescribe melatonin for jet lag not for other conditions such as chronic insomnia or shift work.

Epilepsy Diabetes or impaired glucose tolerance Significant liver or kidney disease (ask your doctor if not sure) Autoimmune disease (any illness caused by antibodies to healthy body organs)

Breastfeeding (risk unknown, not suitable) Pregnant (risk unknown, not suitable) Might become pregnant and not using effective contraception

These medications interact with melatonin: Fluvoxamine - depression, OCD (obsessive compulsive disorder) Psoralen - part of PUVA light treatment for skin conditions like psoriasis Cimetidine - rarely used for stomach acid Oestrogen - combined contraceptives or HRT (hormone replacement) Quinolone antibiotics - rarely used (e.g. ciprofloxacin, moxifloxacin) Other sleeping tablets/remedies Rifampicin - antibiotic for tuberculosis Carbamazepine - epilepsy, bipolar disorder, trigeminal neuralgia Warfarin - blood thinner requiring regular blood tests

Melatonin may impair driving, cycling, and operating machinery

Is there anything you do not understand or do you need further help?

The medication is for my own use and I will not share with anyone else My responses are honest and accurate, and I understand that this is necessary for a safe medical assessment I understand the treatment is for jet lag only I will read the patient information leaflet supplied with the medication I am over 18 and I agree to identity verification checks I have completed this questionnaire myself and fully understand all the information I agree to the terms & conditions, privacy policy, data sharing policy & consent to cookies