Smoking Cessation Appointments

Appointment

Patient Name*

Address*

City*

State*

Zip Code*

Phone Number*

Please enter a valid phone number.

Gender*

MaleFemale

Date of Birth *

Date

Primary Care Provider

Tobacco Types used (Chek all that apply)*

List any medications the patient may take.*

Does the patient have any allergies?*

YesNo

If answered (Yes) to above, list any allergies the patient may have.

1. Do you use tobacco within 30 minutes of waking up?

YesNo

2. Have you ever had a heart attack, irregular heartbeats, chest pain within the last 2 weeks?

YesNo

3. Do you have a history of high blood pressure?

YesNo

4. Have you had previous attempts at quitting smoking?

YesNo

5. Do you have any allergies to adhesives?

YesNo

6. Do you have TMJ disease, braces, fillings, crowns, or dentures?

YesNo

7. Do you have frequent stomach ulcers/diabetes?

YesNo

8. Are you pregnant/breastfeeding/planning on becoming pregnant?

YesNo

9. Are you at risk of myocardial infraction?

YesNo

10. Do you have trouble adhering to medication?

YesNo

11. Do you have asthma/breathing problems?

YesNo

12. Have you recently had an MRI?

YesNo

13. Are you at risk of a heart disease?

YesNo

14. Are you currently adhering to a low-sodium or sodium restricted diet?

YesNo

15. Do you have any seizure disorders?

YesNo

16. Are you at risk for kidney disorders or have renal impairment?

YesNo

17. Do you have any Skin disorders?

YesNo

18. If you are taking cigarettes, do you smoke less than 10 cigarettes daily?

YesNo

By signing this form, I acknowledge that I am voluntarily requesting that my pharmacist consult with me about my tobacco cessation options, and I understand the following:

Pineville Pharmacy is not able to bill insurance for this consultation, the cost of this consultation is non-refundable, and I am fully responsible for the payment prior to the consultation.
I will not seek any reimbursement from Pineville Pharmacy or its employees.
The pharmacist is providing care based on the information that I provide. The pharmacist will explore Tobacco Cessation options, and how to use it.
The pharmacist will try to answer all my questions about Tobacco Cessation, I understand that Pharmacist and Physicians have different educational training.
If the Pharmacist is not able to provide my preference on tobacco cessation options, I will refer to my Primary Care Provider.
Establishing a relationship with a Primary Care Provider is important in Tobacco Cessation therapy, if I do not currently have a relationship with a Primary Care Provider the pharmacist will attempt to establish one.
Receiving prescription/therapy is not adequate replacement for annual check ups with my primary care provider.
No form of tobacco cessation therapy is 100% effective, and the pharmacist is not liable if the methods/therapy provided does not work.
I will contact my Pharmacist and Medical Health Provider with any changes regarding side effects, problems, or changes to my mental and physical health conditions.
I give consent to my pharmacist and pharmacy staff members of Pineville Pharmacy to perform consultations at my own risk and authorize that Pineville Pharmacy and its staff members to possess a copy of my consultation forms.
On behalf of myself, my heirs, and personal representatives, I indemnify the organizing body and all persons connected with Pineville Pharmacy from all outcomes that may result from my voluntary participation in the consultation.

Patient Signature*

Date*

Date

My Products*

Smoking Cessation Consultations

$89.00 Quantity

Total

$0.00

Credit Card