PATIENT INFORMATION AND CONSENT FORM

for Delta Air Lines Malarone Services

Health Care Provider: Passport Health - Phone: 248-227-7237 or 888-909-6551; Fax: 877-440-1795

Crew: $35 assessment billed to Delta.
Ground (non-crew) business traveler: $35 assessment self pay and expense back to dept.
Leisure travel/Spouse/Dependent: $50 assessment charge. Passport Health will call you for billing information.

PATIENT INFORMATION
NAME:
Last

First

Middle
DATE: Dec/11/2017
ADDRESS:
Street

Apt
BIRTHDATE: AGE:

City

State

Zip
SEX: Male
          Female
HOME PH: CELL PH:
EMAIL:
OCCUPATION (select):  Pilot   Flight Attendant   Business Traveler   Leisure Traveler   
    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) Are you pregnant? Yes    No
    3) Are you breastfeeding? Yes    No
    4) Are you hypersensitive or allergic to atovaquone, proguanil or malarone? Yes    No
    5) Do you have severe kidney disease? Yes    No
    6) Are you taking tetracycline antibiotic, rifampin, rifabutin, or rifapentine (anti-Tuberculosis drugs) or any product containing proguanil other than Malarone? Yes    No
    7) When are you leaving? (mm/dd/yyyy)

The above information is accurate to my best recollection. I have been advised that when traveling with my Malarone, I should ensure it is in its original packaging and I have the instructions for taking it. I am responsible for keeping the medications and the instructions for taking them in the labeled package provided to me by this healthcare provider.

Delta Employee Signature: Delta Employee ID:
 

The prescription will be called in.
If you have not been notified within one business day that your prescription has been called in, please call Passport Health at 248-227-7237 or 888-909-6551 to check on the status.

 

*Employee should call their pharmacy to validate that they have 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