Your Cart
0115 8501944
Trustpilot
0115 8501944
0% Complete

Anti-Malaria

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at [email protected]

About You

1. Hi. What is your name?

2. How many travellers are you purchasing this medication for?

3. What is the full name, date of birth and weight of each traveller?

4. What is the registered FULL home address of each traveller? If different.

5. Please tell us the malaria-risk area you are visiting.

Please be specific as commonly, not the whole country needs malaria tablets.

6. When are you first arriving in a malaria area?

7. How many days are the traveller(s) travelling in the malaria area?

The doses for children are based on weight. Please check the Malarone Paediatric FAQs to understand how many tablets you need. Failure to order the correct quantity will delay your order.

8. Does the traveller(s) suffer or ever suffered from the following conditions?

9. Does the traveller(s) take any of the following medications?

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

10b. Please provide more information. If the traveller(s) are pregnant, please advise how many weeks pregnant they are.

11. Do the traveller(s) have any kidney or liver impairment?

11b. Please provide more details

12. Does the traveller(s) have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

12b. Please provide more details

13. Are you allergic to any medicines or other substances e.g. peanuts or soya?

13b. Please provide more details

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

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

14b. What are the traveller(s) GP details. Please provide name and address of the general practice the traveller(s) are registered to.

15. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] 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.
  • Persons taking malaria tablets for prophylaxis or treatment of malaria 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 I requested cannot guarantee 100% protection against malaria. I understand I need to protect myself 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 your medication.
  • The traveller(s) understand that although it is not compulsory, it is essential to inform your GP of this treatment so they can provide safe healthcare.
  • You understand that prescribing decisions will be based on the answers from your consultation, and incorrect information can cause harm to your 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.
  • You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

16. 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.