Please confirm the following:

• I am 18 years old or above.

• I am using this service on my own behalf and of my own free will, and any treatment or advice is for my sole use only.

• I will inform my GP of any treatment I have received.

• I understand my consultation will not be passed to the Be Online Pharmacy team until I have purchased my preferred treatment.

• I agree to  Be Online Pharmacy's terms & conditions and privacy policy.

I confirm and understand all of the above

Please enter your first name.

Please enter your last name.

Please enter your email address.

Please enter your phone number.

What is your date of birth?

What is your sex?

MaleFemale

Are you currently pregnant, trying to conceive or breastfeeding?:*

I am pregnantI am breastfeedingI am trying to conceiveI have given birth in the last 6 monthsNone of the above

What country are you visiting? If you are visiting more than one, please share the first malaria country here.

What area(s) within this country are you travelling to?

Are you visiting any other countries?

YesNo

Please provide more details on the other countries and areas you are visiting.

When are you first arriving in a malaria area?

Have you checked the TravelHealthPro website to see which malaria pills are recommended for the countries you have shared above? 

Visit the TravelHealthPro website 

Please choose your answer.

YesNo

Please visit the TravelHealthPro website to ensure malaria tablets are recommended for your trip.

Does the TravelHealthPro website recommend the same malaria pills for all the countries you have shared above?

Visit the TravelHealthPro website

Please choose your answer.

YesNo

Please book an appointment with your GP or visit our Be Medical Travel Clinic to ensure you get the right treatment.

If you have previously taken malaria tablets, have you experienced any side effects?

YesNo

Please provide more details. Which malaria tablets did you take? What effects did you experience?

Do you have any medical conditions?

YesNo

Please let us know your medical conditions.

Are you currently taking any prescription medications?

YesNo

Please let us know what medications you are taking.

Do you have any allergies that you are aware of?

YesNo

Please let us know what allergies you have.

Would you like us to send this consultation to your GP?

Yes No

We are required to tell your GP if we prescribe you with oral antibiotics. If you do not provide consent or the details of your GP, we will be unable to process your order.

GP practice name.

GP practice address.

Do you give consent for our prescriber to check your NHS summary care records if required?

YesNo

To purchase products from Be Online Pharmacy, you must give our pharmacists consent to access your health records.

Please confirm the following:

All information I have provided is accurate and honest to enable Be Online Pharmacy  prescribers to make the best decision in regards to my health.

I will read, understand and follow the instructions in the patient information leaflet, including the risks and side effects, before taking my treatment.

I am happy for the Be Online Pharmacy clinicians to contact me if necessary to ensure suitability and safety.

I will upload proof of valid ID if requested.

I understand there is a refund fee of £10 if I cancel my order.

I am aware Be Online Pharmacy can refuse or withdraw service without providing a reason (a refund will be issued).

I will seek medical advice via a GP, NHS 111, walk in centre, pharmacy and if necessary, A&E if I experience any adverse effects from my treatment.

I will seek medical advice if my medical circumstances or condition changes.

I confirm all of the above.

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