Medical Assessment - Stop Smoking

Health

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

We are unable to supply you with Champix. Please consult your GP.
You must answer the question to continue

Are you breast feeding or pregnant or possibly pregnant?

We are unable to supply you with Champix. Please consult your GP.
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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
  • any serious medical condition which may require immediate hospitalisation
We are unable to supply you with Champix. Please consult your GP.
You must answer the question to continue
Medication

Are you taking any of the following medications?

  • anti-depression medication
  • cimetidine for gastric problems
  • theophylline, warfarin or insulin
We are unable to supply you with treatment. Please consult your GP.
You must answer the question to continue
Agreement

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

For more information on how to take Champix call the helpline.
You must answer the question to continue

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)?

We are unable to supply you with Champix. Please consult your GP.
You must answer the question to continue

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

For more information on how to take Champix call the helpline.
You must answer the question to continue

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
You must agree to this before continuing. If you need assistance contact customer support.
You must answer the question to continue

Do you agree to the following?

  • You will read the patient information leaflet supplied with your medication
  • 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.
  • The treatment is solely for your own use
  • 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 must agree to this before continuing. If you need assistance contact customer support.
You must answer the question to continue
You must click on the terms and conditions to continue