nicquit.com.au

2026 03 26 nicquit 2 dkblue
Menu
Login
2026 03 26 nicquit 2 dkblue
Menu
Login

Upload Prescription

Upload Your Prescription

Use this form to upload your prescription. A copy of the completed form will be sent to both NicQuit and your email address.

What happens next?

  • ✓ We will review the prescription and check whether we can supply the prescribed items.
  • ✓ If we can supply them, we will create a NicQuit account for you.
  • ✓ You will then be able to purchase your prescribed products online.
⏱ Typical response time: Within 1 hour during business hours.

Personal Details

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.

Your Prescription

Upload a clear photo or scan of your prescription. Accepted formats: PDF, JPG, PNG (max 10MB). *

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)

Do you have any current medical conditions? (optional)

Do you have any of these particular health issues? (optional — tick all that apply)

Are you a member of a Private Health Fund? (optional — tick all that apply)

Additional Nicotine Use Details (optional)

How soon after waking do you first smoke or use nicotine? (optional)

Which other nicotine products do you use now? (optional — select all that apply)

Quit Goals and History (optional)

What are your current goal(s) with respect to quitting? (optional — tick all that apply)

Would you like advice on safer product use or product selection? (optional)

Have you previously tried to quit? (optional)

Clinical Details (optional)

Have you ever had an adverse reaction to nicotine replacement therapy, or medications such as varenicline (Champix), or bupropion (Zyban)? (optional)

Do you use cannabis or other similar substances? (optional)

If yes, do you mix this with tobacco? (optional)

Consent and Acknowledgement Statement *

  1. I confirm that I am over 18 years of age and that this prescription is for my personal use.
  2. I confirm that I will not sell or give smoking cessation products accessed through the NicQuit site to others.
  3. I acknowledge that NicQuit will review my uploaded prescription to check whether the prescribed items can be supplied, and that supply is not guaranteed.
  4. I acknowledge that NicQuit will hold a copy of my prescription 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.
  5. I acknowledge that some smoking cessation products might not be fully approved by the TGA and might not be registered by the TGA.
  6. I accept responsibility for any adverse health effects caused by smoking cessation products accessed through the NicQuit website.
  7. I agree to the Terms and Privacy Policy provided on the NicQuit website.
  8. I consent to NicQuit storing my uploaded prescription and personal or medical information on my online NicQuit account, and to NicQuit's pharmacy partners accessing it as needed to fulfil dispensing orders.
  9. I consent to NicQuit and NicQuit's pharmacy partners accessing my Active Script List online.
  10. I agree to receive marketing material from NicQuit and acknowledge that I can opt out of receiving this at any time.

Upload Prescription Snippet v.1.6