Are you female or male aged between 18 and 65?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you allergic to varenicline or any of the other ingredients in this medicine?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you pregnant or breastfeeding or planning to become pregnant or start breastfeeding during this treatment?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you suffer from any of the following?

Yes No

kidney problems;
liver problems;
depression or other psychiatric disorders;
diabetes;
seizures such as epilepsy;
asthma;
heart problems;
any other chronic conditions we should know about;

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any of the following medication?

Yes No

theophylline (for breathing problems);
insulin;
cimetidine;
medication for depression;
warfarin;
heart medication;

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any other medication not listed above?

Yes No

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you aware that before starting your course of CHAMPIX you should decide on a date in the second week of treatment (between day 8 and day 14) when you will stop smoking. If you are not willing or able to set a target quit date within 2 weeks, you may choose your own target quit date within 5 weeks after starting treatment. If you are not able or willing to quit smoking straight away, you should reduce smoking during the first 12 weeks of treatment and quit by the end of that treatment period. You should then continue to take CHAMPIX 1 mg film-coated tablets twice daily for a further 12 weeks resulting in a total of 24 weeks of treatment?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you understand and agree to stop taking Champix (Varenicline) and contact your doctor or healthcare provider if you experience any of the following conditions?

Yes No

new or worse heart or blood vessel (cardiovascular) problems;
seizures;
increased depression/anxiety, changes in behaviour, agitation, suicidal thoughts;
swelling of face mouth or neck;
unusual skin rash or reaction;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

you have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health;
you will inform your doctor about any unusual side effects;
the treatment is solely for your own use ;
you will read the patient information leaflet supplied with your medication;
you will not exceed the maximum daily dose of this medication ;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Please tick the boxes to confirm the following:

I confirm that I am over 18 and I agree to the Terms and Conditions and the Privacy Policy.

You must accept the terms and conditions to continue!

Medical Assessment