• QuitRX Medical Questionnaire

    Please note that this form is HIPAA-compliant and all data is considered private and confidential, and is stored in accordance to The Privacy Act 2014
  • Thank you for choosing QuitRX to help you with your smoking cessation journey!

    Please read and complete this questionnaire carefully. If you are already vaping, please double check the strengths and volumes that you use before submitting.

    There is a lot of time and effort that goes into assessing individual questionnaires and writing the prescriptions, so please allow up to 24 hours to receive the prescription if approved.

    Disclaimer: QuitRX is not affiliated with any nicotine vaping brands or companies and does not endorse specific brands or products.

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  • New or Repeat Assessment Declaration

    If you have used QuitRX before, some questions will change.

  • Residential Address

    No mail will be delivered to this address. This is used as an identifier but we understand that people may move homes in the year - if so, your prescription does not need to be updated.
  • Age and Intention Declaration

    All medical guidelines strongly discourage use of nicotine for vaping in non-smokers. This service is intended for current/ex-smokers as a method of smoking cessation, and is not appropriate or suitable for non-smokers. We do not prescribe for the purposes of starting nicotine or vaping outside of previous tobacco use. Nicotine Vaping Products (NVPs) are not intended to be used as first line therapy for smoking cessation, and ideally you should have trialled approved forms of Nicotine Replacement Therapies (NRTs). We strongly recommend behavioural support to accompany your smoking cessation journey. 
  • SMOKING HISTORY

  • OTHER MEDICAL HISTORY AND RISK FACTORS DECLARATION

  • VAPING HISTORY

  • Please note that if you are purchasing nicotine products from an overseas supplier, you will receive a PDF prescription so that you can send/upload to your overseas supplier to attach with your package, or as evidence if you are contacted by Australian Border Force.

    However, you cannot use this prescription at pharmacies if they stock your products, as PDF prescriptions have to legally be sent directly from the doctor to prevent people from using the prescriptions at multiple locations.

    If you need a pharmacy prescription (make sure your pharmacy stocks the products first), please go back to select 'From an Australian Pharmacy')

  • TYPES OF NICOTINE PRODUCTS FOR VAPING 

    Premixed liquids
    Usually flavoured between 3mg/ml - 50mg/ml. To re-fill in vape tanks or refillable pods
    'EASY MIX' unflavoured (3mg/ml - 36mg/ml) are types of premix liquids

    Prefilled sealed pods/cartridges
    Usually 1-2ml pods with prefilled liquid with a pod/cartridge device

    Concentrated unflavoured nicotine liquid 100mg/ml
    To DIY dilute with VG/PG and flavoured juices. Discouraged due to risks of accidents and errors. Not recommended for inexperienced users.

    Disposable vapes
    Individual disposable units, multiple puffs, lasts days-weeks. Please note these types of devices are discouraged especially through Personal Importation Scheme due to environmental impacts and counterfeit/quality issues. 

  • PLEASE DOUBLE CHECK YOUR PRODUCT STRENGTHS AND VOLUMES BEFORE SUBMITTING.

    If you ticked more than 1 type above, please be sure to write concentrations/strengths and quantities/volumes for BOTH to be able to write the prescription correctly. If you only write details of one type, you will only be prescribed the one you have provided details for, and any amendments afterwards may incur additional fees.

  • CONSENT AND DECLARATION

    By submitting this form, I declare that all information is true and accurate. I have read the terms and conditions, and privacy policy on the website. I confirm that I am the legal owner of the Drivers License or Proof of Age card and understand that providing false or inaccurate information may be a criminal offense or misusing someone else's identity constitutes identity fraud. I understand that all information is confidential, and may be used by third parties for authorised identity verification purposes only. 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 products registered or approved by Therapeutic Goods Australia. I accept that any risks of using any nicotine vaping products are my own and will keep any nicotine products out of reach of children and adolescents to prevent accidental poisoning. QuitRX is also not responsible for any issues at Customs & Australian Border Force. I understand that amendments after 24 hours of the prescription being sent will incur additional costs, and any amendments after 2 weeks will require a new submission and payment. 
  • PAYMENT FOR PRESCRIPTION

    Note: Due to the importation laws and limits, the prescription usually includes 1 x 3 month supply and 3 repeats for 12 months supply. You can purchase lesser amounts, more frequently as long as the 3 month supply is not exceeded.
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    QuitRX 12-Month Prescription
    $ 70.00 AUD
       
    QuitRX 12-Month Prescription (Concession) Evidence of Centrelink pension card or DVA card must be uploaded. (NOT MEDICARE CARD)
    $ 45.00 AUD
       
    Total
    $ 0.00 AUD

    Payment Methods

    creditcard
    applePay
    After submitting the form, you will be redirected to Apple Pay to complete the payment.
  • To verify your identity and age, please upload your drivers license or proof of age card/passport

    If you have trouble uploading documents, please upload a random picture (I always welcome photos of your pets!) and email a copy of your documents to hello@quitrx.com.au
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  • Sample Centrelink card:  

     

    If you do not have this card or a DVA card, or your card is expired, please select the $70 full fee.

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  • **NOTE: Please make sure you press the submit button once and wait. After a few seconds, if the form submission is successful, you will be taken to a 'thank you' page and receive an email confirmation. Any issues please contact hello@quitrx.com.au

  • PLEASE NOTE: 

    Please contact me (Dr Shu) at hello@quitrx.com.au if there are any issues with submitting the form - I can't fix issues I don't know about!

    There are sometimes issues with browsers not allowing the submission (stuck 'please wait'), if you have issues please refresh the page, clear browser cache, or try a different browser or device. Thanks for your patience!

     

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