Medical and Smoking History Questionnarie

Personal Information

First name

Last name

Date of birth

Gender

Street Address

City/Town

Postcode

Country

Mobile number

Is Valide Number

Online Prescriptions for Vaping

Receive Prescription in 24 Hours

Free Guidance On Your Smoke Free Journey

Vaping History

Which vaping method has worked best for you?

Pods

E-liquid

Disposable devices

Other

What is the minimum strength that has been effective to avoid smoking?

How many mL’s of liquid do you estimate that you use per day?

Is there anything else you would like to add about your vaping?

Medical History

Please list below any significant medical illnesses, such as diabetes, cancer, asthma, COPD/emphysema or psychiatric disorders.

Have you had a stroke, heart attack, irregular heartbeat, uncontrolled hypertension or angina in the past month?

Yes

Are you breastfeeding, pregnant, or planning to become pregnant within the next 12 months?

Yes

Your documents will be securely emailed to you, and no one else, unless you request otherwise. If you would like us to also forward your prescription to a pharmacy, supplier or friend/carer, please enter their email address.

Is there anything else you would like to mention before proceeding?

Complete abstinence from smoking and vaping is the safest option for your health. Nicotine is addictive, and the long-term risks of vaping are unknown. Currently no nicotine vaping products have been approved by the TGA, and the safety of these products has not yet been thoroughly assessed. Quit Clinics, or its doctors, cannot guarantee the safety of any vaping product. In order to minimise risk of harms, only short-term use of e-cigarettes is recommended, and dual use (vaping plus smoking) needs to be avoided.

I confirm that I have read and understand the above safety information

Treatment Selection

12 Month Prescription

An experienced doctor will contact you within 24 hours via email

More information

More Information

An experienced doctor will contact you within 24 hours via email. If they’re unable to help, we’ll provide a full refund.
Prescriptions are valid for 12 months. A copy will be emailed to you, and your chosen supplier/pharmacy, with supporting documents to help you stay on track. A personalised ID card will also be delivered to you via post.
Free ongoing support is available. You can contact your doctor via email anytime by emailing support@quitclinics.com and you’ll receive a response within 24 hours. Request a call or video consultation at any time at no extra charge.

How long is my prescription valid for?

Prescriptions are valid for 12 months

1 Day Test Prescription

An experienced doctor will contact you within 24 hours via email

More information

More Information

How long is my prescription valid for?

Prescriptions are valid for 12 months

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