Book Stop Smoking

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?

(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Yes No

Do you believe you have the capacity to make decisions about your own healthcare?

Yes No

Health

Do you have an allergy (hypersensitivity) to Champix (varenicline tartrate)?

Yes No

Are you breast feeding or pregnant or possibly pregnant?

Yes No

Do you suffer from any of the following?

kidney (renal) disease
depression, anxiety or other psychiatric conditions
history of seizures/epilepsy
diabetes
heart disease/ stroke/ myocardial infarction (heart attack)
any serious medical condition which may require immediate hospitalisation

Yes No

Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Agreement

Do you understand that when starting Champix treatment you should start with a 2 week starter pack?

Yes No

Are you aware Champix increases your chances of quitting smoking but you will also need willpower to succeed (help from family and friends will also help)?

Yes No

Do you understand that you should start taking Champix 1-2 weeks before you stop smoking?

Yes No

Do you understand that you must stop taking Champix and contact your GP or other urgent healthcare provider if you experience any of the following conditions?

new or worse heart or blood vessel (cardiovascular) problems
seizures
agitatation, depressed mood, changes in behaviour, suicidal thoughts
swelling of face, mouth or neck

Yes No

Do you agree to the following?

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No

Stop Smoking - Medical Assessment

Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?

Do you believe you have the capacity to make decisions about your own healthcare?

Do you have an allergy (hypersensitivity) to Champix (varenicline tartrate)?

Are you breast feeding or pregnant or possibly pregnant?

Do you suffer from any of the following?

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Are you taking any of the following medications?

Do you agree to the following?