QuitRX Medical Questionnaire (2022)

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.
Prescription Date

Day Month Year
Date
Prescription Expiry Date

Day Month Year
Date
New or Repeat Assessment Declaration

If you have used QuitRX before, some questions will change.
Have you used QuitRX service before? *

No, this is my first time using QuitRX service (or I am not sure/can't remember) Yes, I have used QuitRX before.
When was your last QuitRX prescription? *
Approximate date/month is fine
Legal Name *

First Name Last Name
Date of Birth *
Format: dd/mm/yyyy
Email *

Confirmation Email Please enter twice to ensure this is correct, or we can't send you your prescription
Contact/Mobile Number *
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.
Street Address *
Suburb *
State/Territory *
Postcode *
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.
I declare that I am over 18 years old to access this service *

Yes
I declare that I am currently/previously a tobacco or cigarette smoker *

Yes
I declare that I am using this service to reduce/quit/keep off smoking *

Yes
SMOKING HISTORY
How many cigarettes do you currently smoke? Please note if you still smoke cigarettes, we strongly advise you to quit this and use vaping as a substitute. *

None, I have completely quit smoking with vaping 1-5 cigarettes a day 6-10 cigarettes a day 11-20 cigarettes a day >20 cigarettes a day
Which best describes you? *

I have reduced cigarette smoking since I started vaping I currently smoke the same amount as I was before vaping I have completely quit smoking
Smoking Status *

I currently smoke cigarettes but want to quit I have completely quit smoking and currently vape nicotine liquids I still smoke but have reduced smoking and currently vape nicotine liquids (please note we encourage to go 'cold turkey' off cigarettes when using vaping as replacement)
How many years have/did you smoke cigarettes for? *

1-5 years 6-10 years 11-20 years >20 years
How many cigarettes do you currently smoke a day? If you have quit, how many cigarettes did you use to smoke a day? *

1-5 cigarettes 6-10 cigarettes 11-20 cigarettes >20 cigarettes
How many times have you tried to quit smoking? *

1-5 times 6-10 times >10 times
Vaping is not first line treatment for smoking cessation. It is considered after first line treatments (including behavioural support and approved pharmacotherapies) have failed. Please tick smoking cessation methods you have trialed previously: *

Cold Turkey Hypnosis/Psychologist counselling Nicotine patches/gum/spray (e.g. Nicabate, Nicorette) Varenicline (Champix) Bupropion (Zyban) Other
OTHER MEDICAL HISTORY AND RISK FACTORS DECLARATION
In the last 3 months, have you had UNCONTROLLED hypertension, irregular heartbeats/arrhythmia, stroke, angina or heart attacks? *

No, I do not have this (or my condition is well controlled) Yes I have this and require frequent medications or hospitalisations.
In the last 3 months, have you had UNCONTROLLED lung disease including asthma, emphysema or COPD? *

No, I do not have this (or my condition is well controlled) Yes I have this and require frequent medications or hospitalisations.
Nicotine vaping may not be safe in pregnancy or breast feeding. If you are or planning to be pregnant or breastfeeding, please contact hello@drshu.com.au first *

I declare that I am not currently or planning to be pregnant/breastfeeding; or I am a male
Please list any diagnosed medical conditions you have, including hypertension, heart disease, lung disease, mental health disorders
Leave blank if none
What regular medications do you currently take, if any?
Leave blank if none
VAPING HISTORY
If you currently vape/previously vaped nicotine, how long have/had you been doing so? *

I'm completely new to vaping Few days to weeks Few months to 1 year 1-2 years More than 2 years
Where are you planning to purchase your nicotine products? *

From an overseas supplier through Personal Importation Scheme From an Australian Pharmacy (please note not many pharmacies stock nicotine products. Make sure they stock what you need before proceeding)
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')
I understand that I can use this prescription only for Personal Importation Scheme. *

Yes
Which store or website are you planning to purchase nicotine products for vaping? *
This gives us a better indication about the types and strengths of products that may be used
Please note that if you are purchasing nicotine products from a pharmacy who stocks the products, only 6 months supply is allowed. The prescription may be sent to your phone as an SMS token if you have a valid medicare card number. Otherwise it will be sent directly to your pharmacy. *

Yes I understand
I have checked that my pharmacy stocks and sells the products I need (please make sure you know your pharmacy stocks it before proceeding with this questionnaire). Only select pharmacies dispense limited products (usually prefilled pods, not other types) *

Yes I know my pharmacy stocks the products I need
Which pharmacy are you planning to purchase your nicotine products? *
Please be specific about which pharmacy so we can find their details to email the prescription to them
Do you have a medicare card? If you do, the pharmacy prescription QR code will be sent directly to your mobile. *

Yes No
What is your medicare card number (10 digits no spaces) *
What is your medicare individual reference number (single digit next to your name) *
Do you have a 16 digit IHI number (usually starting with 8003)? If so, your prescription may be able to be sent to you as an SMS. *

Yes No
What is your 16 digit IHI number (16 digits, no spaces) *
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.
NICOTINE PRODUCT TYPE: What type of nicotine product do you need for the prescription? Do not include what you will not be using moving forward. Choose one if possible, maximum two if needed. *

PRE-MIXED Flavoured E-Liquid (freebase or salts) or 'EASY MIX' - to put in refillable vapes SEALED PRE-FILLED PODS/CARTRIDGES - you have a battery vape device that fits these pods usually 0.7-2ml capacity) DISPOSABLE individual vapes (usually 2-8ml capacity, whole unit is thrown after it's finished) 100mg/ml NICOTINE CONCENTRATE (freebase or salts, NOT 'easy mix') - to mix with VG/PG/Juice - NOT advised for inexperienced users I'm not sure, please email me
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.
NICOTINE STRENGTHS: What strengths/concentrations of nicotine vaping products are you using or planning to use? If you already vape, please check your products first to be sure. *
If you're new and not sure, write 'not sure' and we'll contact you
DAILY QUANTITY: How much do you use per day? (specify ml if premixed liquids) Or how long does each sealed pre-filled pod (or disposable unit if selected) last? Please be specific about each if you use more than 1 type. If you use 100mg/ml nicotine concentrate, please write what strength you mix down to, and how much of the mixed liquid you use. *
E.g. 1ml daily, 5ml daily, or 1 pod lasts 2-3 days,or 1 disposable lasts a week. If you're not sure, we'll discuss with you
3 MONTH QUANTITY: In 3 (THREE ) months or 90 days, how much do you need? If you use freebase/salts/concentrate, how much in ml do you need? If you use sealed pre-filled pods or disposables, please write how many pods or disposables. If you use Concentrated Nicotine, please write the STRENGTH (e.g. 100mg/ml or 50mg/ml) AND QUANTITY of this you need e.g. 100ml/125ml (not the mixed liquid) *
Please don't write "number of bottles" as there are many different sizes. We try to calculate based on daily usage. If you're not sure, we can calculate a volume for you. Please note we will contact you if volumes seem excessive.
Different types of nicotine products need its own concentration and quantities on the prescription. If you do not put down details for both the products that you use, the prescription may only have one product. I confirm that I have put down concentrations and quantities for ALL products *

I only use one type of product I use more than one type, and have written concentrations and daily/3monthly quantities for both
Please briefly describe what products you use/how or when you use the nicotine products (especially if you use 2 different types) to make it clearer for the prescriber to assess and write the prescription. If you mix 100mg/ml concentrate nicotine, please write if you are experienced or if you have help to mix this.
Leave blank if this is straightforward
H RX: Nicotine Type

Pre-Mixed E-Liquid (Freebase or Salts), Including Easy Mix Nicotine Liquid Concentrate (Freebase or Salts) Pre-Filled Pods Disposable Vape Units
H RX: Daily Quantity
H RX: 90 day Quantity
H RX: Strength
H RX2: Nicotine Type

Pre-Mixed E-Liquid (Freebase or Salts) Pre-Filled Pods/Cartridges Disposable Vape Units Nicotine Liquid Concentrate (Freebase or Salts)
H RX2: Strength
H RX2: Daily Quantity
H RX2: 90 day Quantity
H RX: Number of Repeats
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.
I consent and agree to the above declaration statement *

Yes
Purchasing Nicotine Vaping Products for someone else using my prescription is illegal and an offense. I declare that I am obtaining a prescription for my own personal use. *

Yes
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. For pharmacy prescriptions, this will be a monthly supply x 5 repeats for 6 month supply.

Assessment Payment *

QuitRX Prescription (Full Fee)

$ 70.00 AUD

QuitRX 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

Credit Card

Apple Pay

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
uPlease upload Proof of Age card or Drivers License or Passport: *

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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.
If you have a VALID (not expired) Centrelink pensioner/healthcare card or DVA card, please upload here (PLEASE DO NOT UPLOAD MEDICARE OR INSURANCE CARD): *

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Please write any questions or further comments here (if there was any issues with uploading files or initial issues with the form let me know too):
Leave blank if no comments, but we also love to hear about your quitting journeys so please feel free to tell us your story! :)
**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!

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Should be Empty:

QuitRX Medical Questionnaire

New or Repeat Assessment Declaration

Residential Address

Age and Intention Declaration

SMOKING HISTORY

OTHER MEDICAL HISTORY AND RISK FACTORS DECLARATION

VAPING HISTORY

CONSENT AND DECLARATION

PAYMENT FOR PRESCRIPTION

Payment Methods

To verify your identity and age, please upload your drivers license or proof of age card/passport