It can be very difficult to quit smoking. Most smokers experience the withdrawal symptoms as particularly challenging. Quit smoking tablets help you overcome cravings and increase your chances of becoming an ex-smoker. To place your order, fill in our brief medical questionnaire. For additional support and information please review our forum.
Male Patients Note: We can only ever prescribe for this treatment for patients that are at least 18 years of age.
On average how many cigarettes would you smoke per day?*
Do you often find that you smoke cigarettes when consuming alcohol?*
Have you ever tried to quit smoking in the past?*
What attempts have you tried to quit smoking?*
Have you ever used Champix tablets in the past in an attempt to quit smoking?*
Who prescribed Champix tablets for you?*
Did you experience any side-effects after taking Champix tablets?*
Did you ever receive any additional outside support in an attempt to help you quit smoking?*
Are you Male or Female?*
STEP 2 OF 2
Have you been diagnosed with any kidney issues?*
Have you ever been diagnosed with or received treatment for any psychological issues (such as anxiety, panic attacks or depression), or for any psychiatric issues (such as, mania, bipolar disorder or schizophrenia)?*
Have you a history of any medical procedures, operations, or anything you feel that would be of interest to the Doctors reviewing this form, other than issues already mentioned in the form earlier?*
Are you currently pregnant or do you plan of becoming pregnant in the next 6 months?
Are you currently breastfeeding?
What is your current height (enter as centimetres)?
What is your current weight (enter as kg)?
Within the last 2 months have you or are you taking any prescription, non-prescription, recreational/illegal drugs or herbal remedies that you have not already mentioned?*
Do you have any allergies that you know of?*
If you wish to have your prescription sent to a pharmacy of your choosing (place Pharmacy details below)
I confirm that I fully understand and have read completely all questions in this form and all of my answers are true and accurate, to the best of my knowledge.*