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