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Name(Required)

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Gender(Required)

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Your age group(Required)

18-24

25-34

35-44

45-49

50-54

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Smoking and vaping history

Before trying vaping for smoking cessation, I recommend the established nicotine replacement therapies. There are nicotine patches, gums and inhalers. Champix is also recommended if appropriate - it reduces nicotine cravings. Counselling can be highly effective. What have you tried previously? Choose all that apply:(Required)

I tried nicotine replacement therapies, but they had side effects and I couldn't continue (eg rash, headache)

Nicotine replacement therapies helped for a while but I soon resumed smoking

I tried Champix but it didn't suit me (eg worsened mental health, nightmares)

Nicotine replacement therapies are too expensive

I have tried NRT therapies but I'm not interested as they did not work for me, I enjoy the ritual and nicotine benefits of smoking. I just want a healthier alternative

I have not tried first line NRT products like patches, gum, lozenges

Add any free comments about your previous smoking cessation attempts (optional)

I am / was a smoker for:(Required)

(N/A because I haven't smoked before)

Less than 5 years

5 - 10 years

More than 10 years

Approximately how many per day did/do you smoke?(Required)

(N/A because I haven't smoked before)

Less than 5/day

5-20/day

More than 20/day

Vaping history

This doesn't affect your script eligibility. It just helps me to better understand your needs and the role of vaping in your life.

Do you currently vape?(Required)

Yes

No, I haven't tried vaping before

For current vapers

Briefly describe what benefits you have noticed, since switching to nicotine vapes.(Required)

This doesn't affect your script eligibility. It just helps me to better understand your needs and the role of vaping in your life.

When did you start vaping(Required)

Within the past 12 months

1-3 years

More than 3 years ago

How often do you vape(Required)

Not every day

Daily: less than 5 times a day

Daily: 5-10 times each day

Daily: On and off for most of the day

Health conditions

Although vaping is much less harmful than smoking, there are specific health conditions which are potentially impacted by both vaping and smoking. More longterm evidence is still needed to truly understand the impacts of vaping.

Are you pregnant, breastfeeding, or currently trying to conceive?(Required)

This doesn't affect your script eligibility. It just helps me to better understand your needs and the role of vaping in your life.

Yes

If you are pregnant or trying to conceive, or breastfeeding

You are still eligible for a vaping script, but read this information before proceeding:

We know that SMOKING causes significant harm in pregnancy. The main risks are: preterm delivery, low birth weight, birth defects, bleeding during pregnancy and delivery, newborn respiratory problems, and higher risk of sudden infant death syndrome ('SIDS'). This is due mainly to the combustible toxins in cigarettes, including carbon monoxide. But the role of NICOTINE by itself is less known. Animal studies link nicotine to poor newborn growth, and possible brain development concerns including nicotine dependence. Nicotine while breastfeeding can also affect baby's digestion (causing colic and diarrhoea). Also be aware that during delivery at hospital, you will probably not be allowed to vape anywhere on site. I recommend you transition to patches or gums ahead of time, if you cannot stop vaping completely. Labour is difficult enough, without adding nicotine withdrawals! Have an open discussion with your maternity care providers, and they will help you get through this period. So this is what I recommend: - Stay smoke-free. - Vaping is ALWAYS safer than smoking. - If you cannot stop vaping completely, aim to reduce it as much as possible. - Consider reducing your nicotine use by using patches or other types of nicotine replacement therapies. There is more safety evidence for these in pregnancy and breastfeeding, compared to vaping.(Required)

We know that SMOKING causes significant harm in pregnancy. The main risks are: preterm delivery, low birth weight, birth defects, bleeding during pregnancy and delivery, newborn respiratory problems, and higher risk of sudden infant death syndrome ('SIDS').

This is due mainly to the combustible toxins in cigarettes, including carbon monoxide.

But the role of NICOTINE by itself is less known. Animal studies link nicotine to poor newborn growth, and possible brain development concerns including nicotine dependence.

Nicotine while breastfeeding can also affect baby's digestion (causing colic and diarrhoea).

Also be aware that during delivery at hospital, you will probably not be allowed to vape anywhere on site. I recommend you transition to patches or gums ahead of time, if you cannot stop vaping completely. Labour is difficult enough, without adding nicotine withdrawals! Have an open discussion with your maternity care providers, and they will help you get through this period.

So this is what I recommend:
- Stay smoke-free.
- Vaping is ALWAYS safer than smoking.
- If you cannot stop vaping completely, aim to reduce it as much as possible.
- Consider reducing your nicotine use by using patches or other types of nicotine replacement therapies. There is more safety evidence for these in pregnancy and breastfeeding, compared to vaping.

I have read the above, and understand that NO SMOKING OR VAPING is the safest option during conception, pregnancy and breastfeeding.(Required)

Other medical conditions

Do you have any of the following? Select all that apply:(Required)

These specific conditions can potentially be affected by EXCESSIVE NICOTINE. I recommend you reduce your vape use in these conditions, aiming for the minimum nicotine level that still keeps you smoke-free.

Cardiac: Heart arrhythmias (eg atrial fibrillation)

High blood pressure

Epilepsy

None of these

Do you have any of the following? Select all that apply.(Required)

These specific conditions can potentially be affected by INHALED VAPING IRRITANTS. I recommend aiming to reduce your vape use, to the minimum level that keeps you smoke-free.

Respiratory: Asthma

Respiratory: Emphsema/chronic obstructive pulmonary disease

Respiratory: Other lung disease (such as pulmonary fibrosis, asbestosis, 'miner's lung')

None of these

Medications

Do you take any prescribed medication?(Don't include over-the-counter products such as vitamin supplements)(Required)

This doesn't affect your eligibility for a vaping script. But be aware that nicotine may interact with certain medications, affecting the levels.

Yes

MEDICATIONS. The effectiveness of some medications are potentially affected by nicotine. These interactions are well researched with smoking. The effect of vaping is less known. This includes some antidepressants, some antipsychotics (eg clozapine and olanzapine), benzodiazepines (eg valium) and blood thinners (eg warfarin and clopidogrel). Please discuss these with your specialist, and don't make big sudden changes to your current nicotine use.(Required)

List the names of any prescribed medications above.

I have listed all of my medications(Required)

Yes

Your nicotine script

I include enough supply to cover the average heavy smoker's cessation needs. You can choose your preferred strength and flavour from the option shown in this website. The pharmacist will keep track of your repeats for you.

Do you want nicotine liquid, hardware or both?(Required)

NICOTINE LIQUID for refillable devices (salts or freebase)

HARDWARE a Uwell vaping device and/or replacement Pods for use with my nicotine liquids

TO CONFIRM - When approved; your prescription will be sent directly to the pharmacist.

When your prescription is approved you can log in to this website and view & purchase products. You will receive tracking as soon as the pharmacist has despatched your order.

Please double check all entries are as accurate as possible.(Required)

Yes, I have reviewed everything and am ready to proceed

Date Created(Required)

Date Expiry(Required)

Signature(Required)

Your Name
Your Name
Your Name

Payment Status (NEW)(Required)

Doctor's Name(Required)

Dr Matthew Gartrell, FRACGP, MD

Dr Carolyn Beaumont, FRACGP, MD

Authorised Prescriber of Nicotine(Required)

MAP24-0083880

MAP21-0021302

Provider(Required)

5625493J

490054AA

Prescriber(Required)

MED0002235943

2784151

Doctor's Signature(Required)

Dr Matthew Signature

Dr Carolyn Signature

New Form

ZNew Form

Smoking and vaping history

Vaping history

For current vapers

Health conditions

If you are pregnant or trying to conceive, or breastfeeding

Other medical conditions

Medications

Your nicotine script

TO CONFIRM - When approved; your prescription will be sent directly to the pharmacist.