PATIENT INFORMATION AND CONSENT FORM

for Delta Air Lines Malaria Prevention Medication Assessment

Health Care Provider: Passport Health - Phone: 1-866-88-DELTA (1-866-883-3582); Fax: 877-440-1795

Crew: $35 Passport Health assessment is billed to Delta. Prescription: Self-pay by credit card and expense out-of-pocket cost.

Ground (non-crew) business traveler: $35 Passport Health assessment. Self-pay by credit card and expense. Prescription: Self-pay by credit card and expense out-of-pocket cost.

Leisure travel/Spouse/Dependent: $50 Passport Health assessment: Self-pay by credit card. Prescription: Self-pay by credit card.

Complete the following for the Passport Health assessment:

Credit card number:    Expiration Date    CVV Code:

I authorize Passport Health to charge the assessment fee to my credit card.

PATIENT INFORMATION
NAME:
Last

First

Middle
DATE: Mar/22/2019
ADDRESS:
Street

Apt
BIRTHDATE:

City

State

Zip
SEX: Male
          Female
HOME PH: CELL PH:
EMAIL:
OCCUPATION (select):  Pilot   Flight Attendant   Business Traveler   Leisure Traveler   

Was/Is your malaria medication prevention service to be provided at an on-site travel clinic in the training center? Yes    No

    1) Is the screening for purposes of a business trip to an area where malaria transmission is intense? Example: West Africa locations. See Delta Malaria Prevention and Obtaining Malarone and Doxycycline FAQ's for a current list of these destinations. Yes    No
    2) When do you leave to the malaria endemic area?
    3) Are you pregnant or might be pregnant? Yes    No
    4) Are you breastfeeding ? Yes    No
    5) Are you allergic to atovaquone, proguanil or Malarone? Yes    No
    7) Do you have severe kidney disease? Yes    No
    8) Are you taking tetracycline antibiotic, rifampin, rifabutin, or rifapentine (anti-Tuberculosis drugs)? Yes    No
    9) Are you currently taking Malarone or any other product containing atovaquone or proguanil? Yes    No
    10) Are you taking warfarin (Coumadin)? Yes    No

NOTE: Taking atovaquone, proguanil, Malarone (atovaquone-proguanil) or doxycycline while on warfarin (Coumadin) may alter bleeding times.

The above information is accurate to my best recollection. I am responsible for keeping the labeled medication and the administration instructions provided to me by this healthcare provider. I have been advised that when traveling with my malaria medication, I should ensure it is in its Passport Health provided amber container that is labeled with the administration instructions.

Delta Employee Signature: Delta Employee ID:
 

The prescription will be electronically submitted or called in within one business day of your electronic submission.

Call your pharmacy to verify the prescription is available for pick up. If the pharmacy does not have your prescription, call Passport Health at 1-866-88-DELTA (1-866-883-3582) to check on the status.

 

Employee should call their pharmacy to validate that they have atovaquone-proguanil (“Malarone”) available before submitting this form.

Pharmacy Information: Name:
Address:
City, State, Zip:
City

State

Zip
Telephone:
Fax:
Enter the letters and numbers displayed in the image to the left