Book Now Book Now Some prescribing consultations are bulk billed, but it depends on your situation. Do any of the following apply to you? * Select the option that best describes you — this determines whether your consultation is Bulk Billed ($0 out of pocket) or Paid ($40 out of pocket). Please select an option… I am currently experiencing homelessness I am seeking care related to family/domestic violence or sexual assault I live in a regional, rural, or remote area (Modified Monash Model MMM 4–7) I am in COVID-19 (or other directed) isolation/quarantine This is an urgent after-hours consult and I can't reach my usual GP I am receiving specialist psychiatric care and currently live in a residential aged care facility I access care through an Aboriginal Community Controlled Health Service or another eligible health service None of the above apply to me (Go to Paid clinic - $40 out of pocket) Personal Details First Name * Last Name * Date of Birth * Gender (optional) Please choose one Female Male Other Mobile Number * Email Address * Street Address * Suburb * State * — ACT NSW NT QLD SA TAS VIC WA Postcode * Smoking & Vaping History * In the past 12 months, have you smoked cigarettes and/or used a vape / nicotine vaping product (NVP)? Tick any that apply. Not applicable — I have not smoked or vaped in the past 12 months Cigarettes Vape / NVP Average number of cigarettes smoked per day * Preferred strength or brand of cigarette * Brand of vape and/or known % nicotine * Device type * Please select an option… Closed-system (pre-filled pod/cartridge) Open-system (refillable tank) Time/days until a pod or cartridge is empty * Volume of e-liquid used per day * Provide additional information about your health and smoking history. This assists our Pharmacy and Prescriber teams assist you. A record will also be available on your NicQuit account (optional — click to expand) Health Details (optional) Are you pregnant or breastfeeding? (optional — click all that apply) No Pregnant Breastfeeding Do you have any current medical conditions? (optional) No Yes Do you have any of these particular health issues? (optional — tick all that apply) None Diabetes Heart disease / irregular heartbeat / high blood pressure Kidney disease Liver Disease Lung Disease Mental health (e.g. anxiety, depression, schizophrenia) Seizures or Epilepsy Are you a member of a Private Health Fund? (optional — tick all that apply) No Bupa HBF HCF Medibank NIB Additional Nicotine Use Details (optional) Cigarettes on a social/bad day (optional) Nicotine strength of cigarettes (mg) (optional) At what age did you start smoking? (optional) How soon after waking do you first smoke or use nicotine? (optional) 5 min 30 min 60 min >60 min Which other nicotine products do you use now? (optional — select all that apply) None Vapes/e-cigarettes Gum/Lozenge Pouch/Snus Spray/Inhaler Patches How often do you use other nicotine products? (optional) Quit Goals and History (optional) What are your current goal(s) with respect to quitting? (optional — tick all that apply) Quit Now Quit in 3 months Quit in 6 months Quit in 12 months Harm Reduction Reduce cost Reduce social pressure Would you like advice on safer product use or product selection? (optional) No Yes Have you previously tried to quit? (optional) No Yes How many quit attempts have you made? (optional) Longest quit attempt duration (months) (optional) What methods have you previously used to quit? (optional — e.g. patches, medication, counselling, hypnosis) What helped/worked and did not help/work in the past? (optional) Are there others in your household or close friendship group who use nicotine products? If yes, who? (optional) Are there any particular triggers for you to smoke or vape? (optional) Clinical Details (optional) What medications are you currently taking? (optional — prescription / OTC / supplements) What allergies do you have? (optional) Have you ever had an adverse reaction to nicotine replacement therapy, or medications such as varenicline (Champix), or bupropion (Zyban)? (optional) I have never used these Yes Unsure Do you use cannabis or other similar substances? (optional) No Yes, cannabis If yes, do you mix this with tobacco? (optional) Not Applicable Yes No Consent and Acknowledgement Statement * I confirm that I am over 18 years of age and am applying for a prescription solely for my personal use. I confirm that I will not sell or give smoking cessation products accessed through the NicQuit site to others. I acknowledge that prescriptions issued through NicQuit's prescribing partners are for use exclusively on the NicQuit site and that fees are payable if I request access to my prescription for any other purpose. I acknowledge that NicQuit will hold my prescription, if issued, and consent that NicQuit will provide it to their pharmacy partners for dispensing orders raised by me from time to time. I understand that whether a prescription is valid for dispensing is decided solely by the dispensing pharmacy, not by NicQuit. I acknowledge that some smoking cessation products might not be fully approved by the TGA and might not be registered by the TGA. I accept responsibility for any adverse health effects caused by smoking cessation products accessed through the NicQuit website. I agree to the Terms and Privacy Policy provided on the NicQuit website. I consent to NicQuit's prescribing partners sharing my medical information with NicQuit and NicQuit's pharmacy partners and storing it on my online NicQuit account. I consent to NicQuit, NicQuit's prescribing partners and NicQuit's pharmacy partners accessing my Active Script List online I agree to receive marketing material from NicQuit and acknowledge that I can opt out of receiving this at any time. I have read and agree to the above. Continue to Booking Form HubMed Book Now Snippet v.4.10
