Smoking Cessation
Before we are able to prescribe any medications to help with smoking cessation we are going to ask you some questions to ensure it is safe and appropriate for us to issue a prescription. A prescribing clinician, who will authorise the treatment, reviews the answers to these questions. Before proceeding with the questions, please consent the following.
- You are a current smoker
- You will only take the treatment prescribed
- You will alert us of any serious conditions you may have/and any procedures performed on yourself
- You will alert us of any prescription medications you are taking
- You will only use one smoking cessation treatment at a time
- You agree to terms and conditions
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How old are you?
Are you motivated to quit smoking?
Are you currently taking champix?
Do you have a sensitivity to champix?
Select all the following statements that apply to you
About you and your health
Select all the following statements that apply to you
Do you have any of the following medical complaints?
Do you take any of the following medications?
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Full Name
Date of Birth
Email Address
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