Antimalarial treatment questionnaire

Name *

First

Last

Date of Birth *

Email *

Phone Number *

Address *

Select Pharmacy to where treatments should be sent. Select "other" if you can't find your pharmacy *

1. Please share the country you are planning to visit *

2. Please share which areas of the country you will be travelling in *

3. Will you be visiting another country?

Please share *

4. Please enter the date that you will be entering the malaria area *

4.1 Please enter the date that you will be exiting the malaria area *

5. Please confirm that you have checked that the country you are visiting recommends malaria tablets via travelpro website

6. Does the travelpro website recommend the specific malaria tablets you have chosen?

7. If you have taken this medication in the past, did you have any side effects ?