Migraine Application Form Please enable JavaScript in your browser to complete this form.Name *Email *EmailConfirm EmailPhone *Date Of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Best time to call: *Please select time11:00 - 14:0014:00 - 17:0017:00 - 19:00AnytimeNearest Panthera Clinic *Please select location GlasgowPrestonRochdaleSheffieldDo you consent to the collection and processing of your personal data in accordance with the GDPR for the purposes stated in our privacy policy? *YesNoAre you aged 18 years or above? *YesNoHave you been having migraine symptoms for more than 12 months? *YesNoDid the migraine headaches start before the age of 50? *YesNoDoes your migraine episode last for more than 4 hrs if left untreated? *YesNoDo you have more than 3 migraine attacks per month? *YesNoDo you have any history of cancer of any organ system (Excluding skin cancer) within the past 5 years? *YesNoDo you currently have issues with gallstones? *YesNoAre you pregnant or breastfeeding? *YesNoHave ever had a gastric band, gastric leave or any surgery on your stomach to lose weight? *YesNoDo you have Fibromyalgia? *YesNoDo you have trigeminal neuralgia? *YesNoHave you been diagnosed with HIV? *YesNoAre you currently taking medication to prevent your migraines? *YesNoAre you taking part in any other clinical trials? *YesNoBy clicking submit, you are confirming that you have read & understood the Privacy Policy Submit
