Malaria Tablet Request

If Well Travelled Clinics is an Occupational Health provider to your organisation, you can use this form to order malaria tablets.  Please read the Patient Information Leaflet of your chosen anti-malarial carefully, before submitting this form.

We may need to contact you to discuss your request before items are sent.

Here at Well Travelled Clinics we take your privacy seriously and will only use your personal information to provide the services you have requested from us. Before completing this form please take a moment to read our privacy policy in full. Privacy Policy (updated May 2018)

Personal details
Your trip
Enter the duration of your visit by number of weeks in risk area
Medical history
Malaria tablets
Delivery
Items will be sent by Royal Mail Signed For and will require a signature on delivery.
Confirmation