Anti-Malaria

Are you over 40 kg in bodyweight

Are you allergic to any of the following medications or their ingredients?:

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

Do you suffer from any of the following medical conditions?:

• kidney disease
• 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 or have recently finished any medication, including any antibiotics, over-the-counter medication, prescription medication or herbal remedies?

Are you currently pregnant or breastfeeding?

Have you ever been diagnosed with malaria?

Do you have any other allergies we should be aware of?

I confirm that if I experience any flu-like symptoms after returning from my trip for up to a year after returning, and particular within 3 months of return, I will seek immediate medical attention and inform the Doctor/medical team of my recent travel background & history

DISCLAIMER Please consent to the following:

• I confirm the above questions have been answered truthfully and accurately. I understand that any incorrect information may be detrimental to my health
• I confirm the medication is for my personal use only and I should inform my GP of any treatment I receive from e Shop Pharmacy
• I confirm I will take the medication as prescribed or directed for its intended use and I have confirmed the suitability for my choice of anti-malaria treatment on the NHS FitforTravel website
• I have read the patient information leaflet and I will contact a medical professional if I have any questions or experience any side effects while taking the medication
• All information provided will be handled in the strictest confidence in line with GDPR regulations. I am happy for e Shop Pharmacy to collect and use the information I provide for the purposes of providing treatment for my medical condition
• I am happy to be treated by the prescribers and health care professionals at eShop Pharmacy and the final decision on whether to provide treatment will be with the prescriber and or pharmacist
• I understand it is important to avoid mosquito bites and to take this prophylaxis treatment regularly
• I have read and accept the terms & conditions and privacy policy