Nicotine Replacement – Smith Collective

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Are you requesting to purchase nicotine vape liquid for yourself? *

Unable to continue

Sorry, we are unable to continue as patients are only permitted to purchase OTC Nicotine vape medications for themselves (if deemed appropriate by the pharmacist)

Do you have any these Medical Conditions? *

Nicotine Dependence
High Blood Pressure
Heart Disease
Diabetes
Obesity
Asthma
COPD
Other
Anxiety/Depression
No

Please state other medical conditions: *

Are you currently taking any other medications? *

If yes, what medications? *

Are you pregnant or breastfeeding? *

Do you have any know medical allergies? *

I am allergic to: *

Propylene Glycol
Vegetable Glycerine
Nicotine
Menthol
None of these

Are you currently smoking cigarettes? *

How many cigarettes do you smoke a day? *

I don't smoke everyday
Less than 10
Between 11-20
More than 20

How soon upon waking do you have your first cigarette? *

Within 5 mins of waking
Between 6-60min of waking
Whenever I feel like one
I don't smoke everyday

Have you used nicotine vape in the past or, are you currently using a nicotine vape at the moment? *

Are you prescribed nicotine liquid *

What strength nicotine liquid are you currently using? *

How much nicotine liquid do you currently use daily? *

How well are you responding to the current Nicotine liquid you are using? *

Do you have a nicotine vaping device? *

Yes
No
I need a new device

If you need a new device. Please upload a photo of your current device/nicotine liquid

Click or drag a file to this area to upload.

Are you taking another form of Nicotine Withdrawal Treatment? *

Nicotine Patches
Nicotine Gum
Nicotine Spray
Nicotine Lozenges
Prescribed Tablets for Quit Smoking
No, I am not taking another form of Nicotine Withdrawal Treatment
Other

If other please state *

To continue, please acknowledge that you understand Nicotine vaping goods are unapproved by the TGA.

I confirm the pharmacist has informed me:

That the therapeutic vaping goods are unapproved therapeutic goods and not evaluated by the Therapeutic Goods Administration (TGA) for quality (how well it is made), safety, efficacy (how well it works) or performance *

That therapeutic vaping goods are not first-line therapy for smoking cessation or management of nicotine dependence and I have been offered first-line therapy *

currently Are or,

Of the short-and long-term risks versus potential benefit of using the therapeutic vaping good *

How to use the therapeutic vaping goods, including what to do if I experience a side effect *

About nicotine poisoning and what to do if I think that I (or someone else) has been exposed to a vaping substance *

Of contact details for a support service (e.g. Quitline). *

Name *

First

Last

Mobile Phone *

Home Phone *

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Please upload your ID *

Click or drag a file to this area to upload.

order your scripts

Order Over The Counter Nicotine Replacement Vape

Unable to continue

To continue, please acknowledge that you understand Nicotine vaping goods are unapproved by the TGA.