Are you registered with a GP practice in the UK?
Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost
confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with
important information which will help them make an informed decision in deciding if the
treatment is considered to be suitable for you).
Do you believe you have the capacity to make decisions about your own healthcare?
Do you have an allergy (hypersensitivity) to Champix (varenicline tartrate)?
Are you breast feeding or pregnant or possibly pregnant?
Do you suffer from any of the following?
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any of the following medications?
Do you understand that when starting Champix treatment you should start with a 2 week starter pack?
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)?
Do you understand that you should start taking Champix 1-2 weeks before you stop smoking?
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?
Do you agree to the following?