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Asthma
Cold & Flu
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Diarrhoea
Dry Eyes
Dry Scalp
Dry Skin
Ear Infections
Eczema & Dermatitis
Erectile Dysfunction (Ed)
Excessive Sweating
Eye Infections
First Aid
Foot Care
Fungal Nail Infections
Genital Warts
Haemorrhoids & Piles
Hair Loss
Hay Fever
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Insect Repellent
Insomnia
Jet Lag
Lice & Scabies
Menopause (HRT)
Migraine
Nasal Congestion
Nausea
Pain
Period Delay
Premature Ejaculation
Scabies
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Skin Infections
Sore Throat
Stop Smoking
Testing Kit
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No
Please list all of the countries with malaria risk that you will be visiting during your travels:
Have you selected the recommended amount of malaria tablets for the destinations you are visiting? If you are unsure, please vist the Fit for Travel website - https://www.fitfortravel.nhs.uk/home Please DO NOT list the CONTINENT, you will need to specify the countries you are travelling to.
Have you ever had an allergy (hypersensitivity) to anti-malarials?
Yes
No
Have you ever been diagnosed with malaria?
Yes
No
Will you be pregnant or breastfeeding at any point whilst taking this medication or within the next six months?
Yes
No
Do you suffer from or have been diagnosed with any of the following:
Yes
No
Depression or psychiatric disorders.
Epilepsy or convulsions.
Liver disease or kidney disease.
SLE, Myasthenia Gravis or galactose intolerance.
Tuberculosis.
Asplenic or immunocompromised.
Do you take any of the following medication:
Yes
No
Anti-coagulant medications (e.g. warfarin).
Metoclopramide.
Etoposide (a cancer drug).
Rifampicin or Rifabutin.
Tetracyclines.
Valproate.
Barbiturates.
Carbamazapine.
Phenytoin.
Ciclosporin.
Ketoconazole.
Please list any other medical conditions OR allergies you have been diagnosed with.
Enter N/A if not applicable.
Please list any other prescribed medication, over-the-counter medication or recreational products you take.
Enter N/A if not applicable.
Are you aware that if you have recently traveled to a country where malaria is present, or experience flu-like symptoms upon your return from this holiday, it is important to seek immediate medical advice and provide details about your recent travel history?
Yes
Do you agree to the following?
Yes
You will read the patient information leaflet (provided with your medication or by following the relevant link).
The treatment is solely for your own use.
All the information you have provided is accurate. You understand our prescribers can only base decisions on the information provided and that incorrect information can be detrimental to your health.
We need to ensure that this medicine is suitable for the person it is intended for. Therefore may be required to contact you by phone/video call, If we are unable to speak to you when required your order may be delayed.
If necessary you consent to My Pharmacy contacting your GP surgery and/or accessing your Summary Care Records in regards to this treatment.
I consent to receive treatment from My Pharmacy, and confirm that I have the mental capacity to do so. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always rest with the prescriber and is subject to approval. If treatment is not suitable, you will be signposted to another point of care.
You will seek medical advice if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
You will inform your GP with regards to this prescription (It is best practice to inform your GP of any private treatment you receive. All treatment is completely confidential).
Terms & Conditions
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