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Gender:
Date of birth
Have you ever been diagnosed with malaria?
Can you please provide more details?
For further information kindly contact our patient support team:
0207 867 3932
email help@clickpharmacy.co.uk.
Have you checked with the website fitfortravel.nhs.uk/destinations to ensure that the malaria tablets you have chosen are suitable for the countries you are visiting?
Are you pregnant or breastfeeding or may become pregnant or start breastfeeding whilst taking this medication?
Do you suffer from any of the following?
Are you taking any of the following medication?
Please provide the name, dosage and the reason why you are taking that medication or medications.
Are you taking any other medication not listed above?
Are you allergic to mefloquine hydrochloride, atovaquone, proguanil hydrochloride, doxycycline, tetracyclines or to any of the ingredients in the anti-malaria medication (such as lactose)?
Are you aware and agree to the following?
Please tick the boxes to confirm the following:
Order before 15:00pm (Monday to Friday) for next day delivery
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