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Disclaimer - Smoking Consultation

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

What is your gender?
What is your Date of Birth?
Day
Month
Year

If Yes Give Details

If Yes Give Details

If Yes Give Details

If Yes Give Details

Are you currently using any medications/treatments to help you stop smoking?
Do you feel addicted to smoking?
Have you tried to quit smoking before?
On a scale of 1 to 10, how motivated are you to quit smoking?
Have you previously been prescribed pain relief medication for this condition?

If Yes Please provide more information

I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform my own regular doctor of
Would you like us to inform your GP?
Product
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