Anti-malaria

About You

1. Hi. What is your name?

2. Please provide details of each person:

Traveller 1st Details

Add address if different

3. If you're purchasing medication for a child under the age of 18, please provide the parent/guardian's full name, contact number and email address:

Please note that orders for children under the age of 18 cannot be placed on their own and the accompanying adult must also be placing an order.

4. Please confirm your travel destination:

Please be specific regarding your destination as sometimes only specific locations within a country may require malaria prevention.

4b. Please specify the region/ cities you are visiting within each country:

5. Please specify the region/ cities you are visiting within each country:

6. Please provide the date of first entering the malaria endemic area, and when you will be leaving the area:

Departure Date

Return Date

7. Have any of the traveller(s) suffered from, or are currently suffering from the following conditions?

Porphyria

Myasthenia Gravis or Systemic Lupus Erythematosus

Severe kidney problems/ reduced kidney function

Severe liver problems/ liver impairment

Blackwater fever

None of the above

9. Are any of the female traveller(s) pregnant, breastfeeding or planning to become pregnant?

Yes No

9b. Please provide more information. If pregnant, please advise how many weeks:

10. Do any of the traveller(s) have any other medical condition(s) (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Yes No

10b. Please provide more information:

11. Are any of the traveller(s) allergic to any medicines or substances (e.g. peanuts, soya, etc.)?

Yes No

11b. Please provide more information:

12. Would you like us to pass on the details of this treatment to your GP?

Orders for children will need their details to be sent to their registered GP(s).

Yes No

12b. What are the traveller(s) GP details. Please provide name and address of the general practice the traveller(s) are registered to.

Please Provide GP Email (preferred):

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13. Do all traveller(s) agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at enquiries@thefamilychemist.co.uk so we can talk through your options.

The traveller(s) have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
The traveller(s) taking malaria tablets for prophylaxis or treatment of malaria understand that they should take a repeat dose if they vomit within 1 hour of dosing. In the event of diarrhoea, normal dosing should be continued.
The traveller(s) understand that the malaria pill requested cannot guarantee 100% protection against malaria. They understand they need to protect themselves from mosquito bites even when taking this malaria pill. These extra precautions include insect repellents and using mosquito nets.
The traveller(s) understand the importance of completing the entire course of malaria pills.
You have answered the questions honestly and accurately.
The traveller(s) will read and understand the patient information leaflet, Atovaquone/proguanil,Malarone paediatric, and Doxycycline, supplied with the medication.
The traveller(s) understand that although it is not compulsory, it is essential to inform their GP of this treatment so they can provide safe healthcare.
The traveller(s) understand that prescribing decisions will be based on the answers from this consultation, and incorrect information can cause harm to their health. Orders may be rejected if not clinically suitable.
The traveller(s) are aware that The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
The traveller(s) have read and agreed to our Terms and Conditions, Terms of Use and Privacy Policy.

Yes No

14. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.

Yes

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Anti-malaria

About You

Traveller 1st Details

0115 850 1944

enquiries@thefamilychemist.co.uk

Unit 1, Wilford Business Park,
Ruddington Lane,
Nottingham,
NG11 7EP

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About You

Traveller 1st Details

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