Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Do you believe you have the capacity to make decisions about your own healthcare?

Are you allergic to any of the following:

• Atovaquone or proguanil chloride (Malarone)
• Doxycycline
• Mefloquine (Lariam)
• Quinine or Quinidine
• Chloroquine
• Any antibiotics

Have you ever been diagnosed with malaria?

Are you pregnant or breastfeeding or intending to become pregnant or start breast feeding?

Have you been diagnosed with any of the following?

• kidney disesase
• liver disease
• mental health conditions (including depression or anxiety)
• epilepsy or convulsions
• myasthenia gravis, a condition characterised by muscle weakness, difficulty chewing and swallowing and slurred speech
• systemic lupus erythematosus (SLE)
• porphyria (a genetic disorder of the blood)
• Blackwater fever
• any serious medical condition which may require immediate hospitalisation

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Have you confirmed the malaria tablets you have chosen are suitable for the countries you are visiting by checking the NHS fitfortravel website ?

Do you understand that if you experience any flu-like symptoms after returning from your trip for up to a year after you return, you should seek immediate medical attention and tell the doctor about your background and recent travel history?

Do you agree to the following?

• I confirm I am over 18 years old.
• The medicine ordered is for my sole use only.
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
• You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.