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Date of birth
Are you female or male aged between 18 and 65?
For further information kindly contact our patient support team:
0207 867 3932
Are you allergic to varenicline or any of the other ingredients in this medicine?
Are you pregnant or breastfeeding or planning to become pregnant or start breastfeeding during this treatment?
Do you suffer from any of the following?
Can you please provide more details?
Are you taking any of the following medication?
Please provide the name, dosage and the reason why you are taking that medication or medications.
Are you taking any other medication not listed above?
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?
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?
Do you agree to the following?
Please tick the boxes to confirm the following:
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