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?
Are you currently smoking?
For how many days have you been taking champix?
Do you have any allergies?
Do you have a history of epilepsy, seizures or condition that lowers the seizure threshold?
Do you currently, or have a previous history of any psychiatric illness such as schizophrenia, bipolar disorder or depressive disorder?
Have you experienced any of the following side effects?
  • agitation
  • depressed mood
  • changes in behaviour that are of concern to you or your family or if you have developed suicidal thoughts or behaviours
  • insomnia
  • seizures
  • signs and symptoms of heart attack or stroke (includes chest pain, shortness of breath, feeling weak and/or lightheaded, overwhelming feeling of anxiety, slurred or incomprehensible speech, weakness or numbness in one or both arms, leg or side of body, drooped face or eye. sudden vision problem, headache or trouble walking
Do you take any other medication?
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.
Can we pass on details of your treatment to your GP?
I agree that
  • I will stop treatment of Champix 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).