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Online Consultation

Please answer all questions honestly and completely so our health professional can ensure suitability and prevent any delays in supplying your medication

Are you purchasing this medication for yourself?
Are you over 18?
Do you currently smoke?
Please enter the date you stopped, or will stop smoking
Are you pregnant, trying to become pregnant or breastfeeding?
Do you take any of the following medication: aminophylline, theophylline, chlorpromazine, clozapine, erlotinib, flecainide, methadone, olanzapine, riociguat, warfarin?
Do you take any other medication or have any other medical conditions ?
Do you have any allergies?
Do you currently, or have a previous history of any psychiatric illness such as schizophrenia, bipolar disorder, depression, anxiety, panic attacks or ADHD?
Do you have a history of epilepsy, seizures, a condition that lowers the seizure threshold or ever had a serious brain injury?
Do you suffer or have you ever suffered from cardiovascular disease including but not limited to coronary heart disease, angina, myocardial infarction (heart attack), heart failure, stroke, transient ischaemic attack (TIA), peripheral arterial disease, aortic disease, arrythmias such as atrial fibrillation, deep vein thrombosis, pulmonary embolism or congenital heart disease?
Have you been previously diagnosed with moderate or severe kidney disease, impairment or told your eGFR < 30mL/minute/1.73m2
I will read the patient information leaflet before using any provided treatments.
I agree that
  • I will stop treatment of Champix (Varenicline) if I develop agitation, depressed mood, changes in behaviour that are of concern to myself or my family, or if I develop suicidal thoughts or behaviours and will inform my doctor immediately.
  • Before every supply, I agree to be contacted by a pharmacist from Menschem to ensure the treatment is suitable.
  • All questions have been answered to the best of my knowledge.
  • I am happy for pharmacists to review my consultation and prescribe the item requested if it is clinically suitable for myself.
  • I understand my treatment request may be rejected due to clinical or other reasons.
  • The treatment is solely for my own use and not for the use of others.
  • I consent for SPK Pharma Ltd to undertake an ID check to confirm my age and identity. (This will be done using a credit check agency, no record will be put on your credit rating).
I understand that Menschem will not inform my GP of this consultation, unless specifically requested via emailing [email protected] (please include GP name, address, and email address).