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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 enquiries@thefamilychemist.co.uk

About You

1. Are you purchasing this medication for yourself?
2.Enter your weight
st lb DONE
3. Are you breast feeding, pregnant or planning to become pregnant?
4. Please tell us the country or countries you are visiting
5. When are you first arriving in a malaria area?
6. Have you looked on the fitfortravel website (www.fitfortravel.nhs.uk) to ensure the specific malaria pills you are requesting are recommend in the countries you have listed above?

Please Check out the website to confirm if anti-malarial tablets are needed for your trip. Please contact our patient support team on 0115 8501944 or enquiries@thefamilychemist.co.uk so we can talk through your options.

Past Medical History

7. Do you have any kidney or liver impairment?

Please provide more details:

8. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Please provide more details:

9. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Please provide more details:

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

Please provide more details:

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

12. Do you 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.

  • You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
  • I understand that the malaria pill I have requested cannot guarantee 100% protection against malaria. I understand that I need to protect myself from mosquito bites even when taking this malaria pill. These extra precautions include insect repellents and using mosquito nets.
  • I understand the importance of completing the full course of malaria pills.
  • You have answered the questions honestly and accurately and the treatment is solely for your personal use.
  • You will read and understand the patient information leaflet supplied with your medication.
  • You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
  • You understand 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.
  • You are aware 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.

I confirm that I have read the information in this questionnaire and will follow the advice shown here and in the product leaflet

Please click "Yes".