Malaria Drug Information Sheet

Malaria Drug Information Sheet

This form will be sent directly to the pharmacy and a prescription will be generated for you. Please wait 24 hours to pick up medication. There is a $40 prescribing fee to be paid now, plus any copay to be paid when medication is received.
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient DOB*
Patient Weight
Required for Children
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Medical Conditions
Allergies*
Do you want us to bill insurance?*

YesNo, I will pay out of pocket
Last 4 digits of SSN*
This will be used to get your insurance information.
Copy of Insurance Card, Front and Back*

Cancelof
Travel Destination(s)*
Date Entering*
Date Leaving*
Which Malaria Medication would you like to receive?*

MalaroneDoxycyclineNo Preference - Pharmacist Pick

Please answer the following questions*

	Yes	No	Unsure
Are you pregnant or breastfeeding?
Do you use oral birth control?
Do you take tetracycline, metoclopramide, rifampin, or rifabutin?
Do you take carbamazepine, barbiturates, or phenytoin?
Do you have severe renal (kidney) impairment?
Are you on anticoagulant therapy (blood thinners)
Are you on penicillin?

My Products*

Malaria Prescribing FeePrescribing Fee

$40.00 Quantity

Total

$0.00