Doctor Consult ($40)

This online assessment will be sent to a doctor to assess your options for smoking cessation. This will take approx. 2 minutes to complete.

Step 1/5

Your details

First Name *

Surname *

Email *You must use the same email address you used to register with Smartstop

Mobile *Mobile number must start with 04 and not contain any spaces

EmailOld *

DOB *YOU MUST BE 18 YEARS OR OLDER

Sex *

MaleFemaleOther

Street Address *

Suburb *

Postcode *

State *

Country *

Medicare Details

Medicare Number *You 10-digit medicare number

Medicare Index Number *The number next to your name

Medicare Expiry Month *

Medicare Expiry Year *

Medicare Expiry Date

Step 2/5

Assessment

Have you had an online assessment via Smartstop before? *

This is my first time using SmartstopI have previously received a Smartstop prescription and need a new prescription or repeats

Nicotine products may only be purchased and consumed by the patient for whom the prescription is written. Supplying these products to other individuals is illegal. Do you accept to only use this prescription for your own personal usage? *

Yes, I declare that I am obtaining a prescription for my own personal use.No, I do not

We cannot provide you with a prescription at this time.

Step 3/5

Patient History

Cigarette/Tobacco Status *

I am a smoker looking to reduce or eliminate my use of tobaccoI am a smoker but I also use Nicotine Vaping Products to reduce the amount I smokeI have quit smoking and currently Nicotine Vaping Products only

How many years have/did you smoke for? *

1-3 years4-9 years10+ years

How many times have you tried to quit? *

Less than 5 timesBetween 6-10 timesOver 10 times

Please tick the smoking cessation methods you have tried previously *

Vaping History

How often and for how long have you used Nicotine Vaping Products? *

I have never used Nicotine Vaping ProductsI am new but have tried Nicotine Vaping Products (Within 6 months)I have used Nicotine Vaping Products for a while (6 months to 2 years)I have used Nicotine Vaping Products regularly (Over 2 years)

Are you or have you used Nicotine Vaping Products to help you reduce or quit smoking? *

Yes, I have managed to quit or reduce my smoking with vapingNo, I still smoke the same amountI'm new and I'm not sure yet

Step 4/5

Medical History

In the last 3 months, have you had UNCONTROLLED hypertension, irregular heartbeats/arrhythmia, stroke, angina or heart attacks? *

NoYes - please write in the comments what uncontrolled cardiac problems you have

Do you have diagnosed UNCONTROLLED lung disease including asthma, emphysema or COPD *

NoYes - please write in the comments what uncontrolled lung problems you have

Please list any diagnosed medical conditions you have, including hypertension, heart disease, lung disease, mental health disorders

Are you currently or planning to be pregnant or breastfeeding? *

No, I am not pregnant/breastfeedingYes, I am pregnant/breastfeeding

Nicotine for Vaping has not been shown to be safe in pregnancy or breastfeeding and is not advised.

We cannot help you with a prescription at this time.

Please see your GP for further advice.

Step 5/5

Type of Smartstop products

Please note that each unit should last at least 5-6 days. In some cases, heavy smokers may consume these in a shorter amount of time, however, we do not recommend more than 1 unit every 3 days.

Usage: Please choose the closest usage to what you need. *

Zero to one (0-1) vape pod/cartridge every six (6) days (up to 5 units monthly / 15 units 3 months)One (1) vape pod/cartridge every three (3) days (up to 10 units monthly / 30 units 3 months)One (1) vape pods/cartridges every two (2) days (up to 15 units monthly / 45 units 3 months)I'm not sure, please prescribe an appropriate amount based on my smoking history

Patient Declaration

This service is provided for individuals seeking to reduce/eliminate their smoking habit and/or usage of tobacco. This service is not intended for individuals who do not or have not previously been smokers. As per RACGP guidelines, Nicotine Vaping Products are not encouraged as long-term or first-line therapies as the long-term effects of these products do not have sufficient long term study data. From a harm reduction perspective, Nicotine Vaping Products are provided as an alternative option to smoking cigarettes or tobacco.

In order to access Nicotine Vaping Products, patients need to be 18 years or older, a previous tobacco/cigarette smoker and are trying to reduce or quit smoking.

I confirm that I am 18 years or older *

I confirm that I am using this service for smoking cessation *

I confirm that I am currently or have previously smoked cigarettes/tobacco *

By submitting this form, I declare that all the information I have provided is true, accurate, and correct in each and every particular. I understand that providing false or misleading information is a criminal offence. I confirm that I am the legal owner of the Driver’s License or Proof of Age card submitted with this application and I authorise Smartstop to make enquiries to third parties in order to verify and assess the identity information I have submitted. I understand that all information I have provided is confidential and will only be used by Smartstop in accordance with its Privacy Policy which I have read and understand. I understand that nicotine is an addictive substance with potentially harmful effects to users or bystanders, and its short or long term effects are largely unknown. I am aware that there are no nicotine vaping products registered or approved by the Therapeutic Goods Administration. I accept that the risks of using nicotine and will keep any nicotine products out of reach of children and adolescents to prevent accidental poisoning. I acknowledge that a doctor may, based on the information I have provided, choose not to prescribe me with a nicotine vaping product if the doctor considers that such a treatment would be inappropriate based on my personal circumstances. I confirm that I will inform my doctor of any changes to my circumstances (e.g. change of contact details), and have read and understood Smartstop’s terms and conditions and shipping and returns policy.

Please note: Nicotine Vaping Products are not first-line smoking cessation treatments. If you have not discussed with your GP or pharmacist and trialled approved medications/pharmacotherapy, you are not eligible for a prescription. Going 'cold turkey' or reducing cigarettes is not an 'approved pharmacotherapy'

Any additional questions or information to add (Feel free to leave blank)

Payment *

Pay

Refunds will not be issued if you are deemed to be illegible for a prescription as you are having a consult with a doctor.

Save and Complete Later