Nicotine Pouch - Online Assessment

Medical Questionnaire

Please note that this form is HIPAA-compliant and all data is considered private and confidential, and is stored in accordance to The Privacy Act 2014. ©2021 QuitRX
Thank you for choosing QuitRX to help you with your smoking cessation journey!

Please read and complete this questionnaire carefully. Please double check the strengths and quantities that you use before submitting. If you are not sure, please select options that reflect this so that we can contact you prior to writing the prescription.

There is a lot of time and effort that goes into assessing individual questionnaires and writing the prescriptions, so please allow up to 24-48 hours to receive the prescription if approved.

NOTE: It is not legal or ethical to backdate prescriptions, and any requests for this will be declined.

IF YOU HAVE AN IMPORT AT BORDER FORCE WITHOUT A VALID PRESCRIPTION AT THE DATE OF IMPORT, THE IMPORT PACKAGE WILL BE DESTROYED.

Disclaimer: QuitRX is not affiliated with any nicotine pouch brands or companies and does not endorse specific brands or products. QuitRX does not prescribe tobacco-containing products like 'heated tobacco', or tobacco containing snus.

**Many nicotine pouch brands are owned by Big Tobacco. Please do your research and do your best to not to support Big Tobacco brands.
Prescription Date

DayMonthYear
Date
Prescription Expiry Date

DayMonthYear
Date
New or Repeat Assessment Declaration

If you have used QuitRX before, some questions will change.
Are you a resident living in Australia or a traveller?*

I usually live in AustraliaI'm a temporary travellerOther
Have you used QuitRX service before?*

No, this is my first time using QuitRX service (or I am not sure/can't remember)Yes, I have used QuitRX before.
I understand that this is an assessment for Tobacco-Free Nicotine Pouches (for usage under the lip) under the Personal Importation Scheme. For Nicotine Vaping Products, please return to www.QuitRX.com.au and select the correct assessment.*

Yes, I am ordering tobacco-free nicotine pouches from overseas and need an assessment/prescription for Personal Importation Scheme
We do not prescribe more than 12,000mg of nicotine in pouches for a 3 month period. Please ensure you check the total amounts of nicotine you are importing.*

Yes, I have checked that I am importing within this limit
IMPORTANT INFORMATION - PLEASE READ

This service is only available for patients 21 years and above. If you are younger than 21, please speak to your GP regarding approved therapies.

We do not prescribe more than 12,000mg of nicotine in pouches for a 3 month period. Please ensure you check the total amounts of nicotine you are importing.

This is roughly 40 cigarettes worth of nicotine a day.

As nicotine pouches are currently unapproved therapeutic goods, if you require more than this amount for smoking cessation, you should discuss with your doctor regarding supplementing or switching to approved therapies if you have not done so.

You may continue with the assessment, however there will be the above limits on the prescription. If you have already imported products over these limits, this may not be allowed to enter Australia at Border Force. If you have products that meet these limits, it may still be allowed through. Please note we are not liable for any issues at Border Force.

When was your last QuitRX prescription?*
Approximate date/month is fine
Legal Name*

First NameLast Name
Date of Birth
Format: dd/mm/yyyy
Date of Birth*

DayMonthYear
Date
Email*

Confirmation EmailPlease enter your email address twice to ensure this is correct, or we can't send you your prescription
Contact/Mobile Number*
Residential Address

No mail will be delivered to this address. This is used as an identifier but we understand that people may move homes in the year - if so, your prescription does not need to be updated. If you currently reside overseas and will be traveling to Australia, please put in details of where you may be staying in Australia.
Street Address*
Suburb*
State/Territory*
Postcode*
Age and Intention Declaration

All medical guidelines strongly discourage use of nicotine in non-smokers. This service is intended for current/ex-smokers as a method of smoking cessation, and is not appropriate or suitable for non-smokers. We do not prescribe for the purposes of starting nicotine replacement outside of previous tobacco use. Nicotine Vaping Products (NVPs) or Nicotine Pouches are not intended to be used as first line therapy for smoking cessation, and ideally you should have trialled approved forms of Nicotine Replacement Therapies (NRTs). We strongly recommend behavioural support to accompany your smoking cessation journey.
I declare that I am over 21 years old to access this service. If you are younger than 21, please discuss approved nicotine replacement therapies with your GP.*

Yes
I declare that I am currently/previously a tobacco or cigarette smoker*

Yes
I declare that I am using this service to reduce/quit/keep off smoking*

Yes
SMOKING HISTORY
In a day, how many cigarettes do you currently smoke? If you are an ex-smoker, how many cigarettes did you use to smoke a day? Please select the most applicable option.*

Current smoker, 1-5 cigarettesCurrent smoker, 6-10 cigarettesCurrent smoker, 11-20 cigarettesCurrent smoker, 21-40 cigarettesCurrent smoker, >40 cigarettesEx-smoker, 1-5 cigarettesEx-smoker, 6-10 cigarettesEx-smoker, 11-20 cigarettesEx-smoker, 21-40 cigarettesEx-smoker, >40 cigarettes
How many years have/did you smoke cigarettes for?*

1-5 years6-10 years11-20 years>20 years
When was your last cigarette/tobacco use?*

TodayWithin the past 1-4 weeksOver 1 - 6 months agoOver 6 - 12 months agoOver 1 -2 years agoOver 2 -5 years agoOver 5 years ago
How many times have you tried to quit smoking?*

1-5 times6-10 times>10 times
Nicotine pouches are not first line treatments for smoking cessation. It is considered after first line treatments (including behavioural support and approved pharmacotherapies) have failed. Please tick smoking cessation methods you have trialed previously:*

Cold TurkeyHypnosis/Psychologist counsellingNicotine skin patchesNicotine gum, quick mist, oral strips or lozengesVarenicline (Champix)Bupropion (Zyban)Vaping products - nicotine or nicotine freeOther
How confident are you with your plans to quit SMOKING?

Very confidentSomewhat confidentNot very confidentNot confident at allI have already quit smoking, and now only using nicotine replacementOther
OTHER MEDICAL HISTORY AND RISK FACTORS DECLARATION
In the last 3 months, have you had UNCONTROLLED hypertension, irregular heartbeats/arrhythmia, stroke, angina or heart attacks?*

No, I do not have this (or my condition is well controlled)Yes I have this and require frequent medications or hospitalisations.
In the last 3 months, have you had UNCONTROLLED lung disease including asthma, emphysema or COPD?*

No, I do not have this (or my condition is well controlled)Yes I have this and require frequent medications or hospitalisations.
Nicotine may not be safe in pregnancy or breast feeding. If you are or planning to be pregnant or breastfeeding, please contact hello@quitrx.com.au first*

I declare that I am not currently or planning to be pregnant/breastfeeding; or I am a male
Please list any diagnosed medical conditions you have, including hypertension, heart disease, lung disease, mental health disorders
Leave blank if none
What regular medications do you currently take, if any?
Leave blank if none
Dental Check Ups - which best applies to you?*

I have good dental and gum health, and have visited the dentist in the past 12 monthsI have good dental and gum health, but have not visited the dentist in the past 12 monthsI have poor dental and gum health, and have visited the dentist in the past 12 monthsI may have poor dental and gum health, but have not been to the dentist in the past 12 monthsOther
NICOTINE POUCH USAGE HISTORY
Please read further information regarding Nicotine Pouches governance on the TGA website.
- Nicotine pouches are currently unapproved therapeutic goods. There is no robust evidence regarding long term safety and side effect profile. If you have quit smoking successfully with nicotine pouches, I advise you to consider this reducing/ceasing usage of nicotine pouches as soon as possible to reduce risk of side effects.
- Make sure to keep nicotine pouches away from children due to risks of nicotine poisoning from accidental ingestion
If you currently or previously use nicotine pouches, how long have/had you been doing so?*

I'm completely new to nicotine pouchesFew days to weeksFew months to 1 year1-2 yearsMore than 2 years
Have nicotine pouches been helpful in reducing/quitting smoking when you used them?*

Yes they have been helpfulNo they have not been helpfulI am not sure if they have been helpfulI have not tried them yet to know if they are helpful
Have you spoken to your doctor/GP about getting a prescription for nicotine products? (Please answer honestly for research purposes, it does not affect the outcome)*

YesNo
[What happened when you spoke with your GP about nicotine pouch products?]*

They were not supportive of nicotine pouches, or prescribing themThey were supportive of nicotine pouches, but did not know how to prescribeOther
[What is the reason that you have not spoken to your doctor/GP regarding nicotine pouch products? Please select any that apply.]*

I do not have a regular GPI am embarrassed or worried to speak to my GP about thisIt is difficult for me to find time to see my GPI think I am able to manage smoking cessation on my ownMy GP has a long waitlist and it is difficult to get an appointmentOther
Which store or website are you planning to purchase nicotine pouches?*
This gives us a better indication about the types and strengths of products that may be used
MAXIMUM NICOTINE STRENGTHS: What is the closest HIGHEST strength of nicotine pouch products you are using or planning to use? **Note: we do not prescribe strengths over 20mg/pouch.*

3mg/pouch6mg/pouch9mg/pouch12mg/pouch16mg/pouch20mg/pouch
MINIMUM NICOTINE STRENGTHS: What is the closest LOWEST strength of nicotine pouch products you are using or planning to use?*

3mg/pouch6mg/pouch9mg/pouch12mg/pouch16mg/pouch20mg/pouch
NICOTINE STRENGTHS: What is the maximum strength(s)/concentration(s) of nicotine pouch products are you using or planning to use? **Note: we do not prescribe strengths over 20mg/pouch. If you have selected 20mg/pouch maximum strength, we can prescribe no more than 10 pouches per day.
How many mg/pouch of nicotine does your product have?
DAILY QUANTITY: How many pouches do you use a day? If you have never used them before, write 0.*
Please do not report excessive quantities for bulk purchase. These will be reduced on the prescription to reasonable amounts. We do not advise or prescribe more than 10 pouches a day.
Do you already have an order held at Border Force by TGA (Therapeutic Goods Australia)?*

Yes, I have an order held, and asked to provide a prescription.No, I do not have an order held, but expecting some to arrive.No, I do not have an order held, and have not yet ordered/shipped.
Are you planning to quit nicotine pouches?*

Yes, aiming within the next 3 monthsYes, aiming within the next 6 monthsYes, aiming within the next 12 monthsYes, but not sure whenNo, I foresee needing to use nicotine pouches indefinitely.
If you have received a TGA LETTER about your imported nicotine pouches, please upload this here so we can double check the details. DO NOT UPLOAD YOUR ORDER RECEIPT OR BORDER FORCE LETTER, as this does not have the required information.

DO NOT UPLOAD THE ORDER RECEIPT OR BORDER FORCE LETTER AS THIS DOES NOT PROVIDE THE REQUIRED INFORMATION
Cancelof
H RX: Daily Quantity
H RX: 90 day Quantity
H RX: Strength
H RX: Number of Repeats
CONSENT AND DECLARATION - PLEASE READ

By submitting this form, I declare that all information is true and accurate. I have read the terms and conditions, and privacy policy on the website. I confirm that I am the legal owner of the Drivers License or Proof of Age card and understand that providing false or inaccurate information is a criminal offense or misusing someone else's identity constitutes identity fraud. I understand that all information is confidential, and may be used by third parties for authorised identity verification purposes only. I understand that nicotine is an addictive substance with potentially harmful effects to users or bystanders, and its short or long term effects are largely unknown. I am aware that there are no products registered or approved by Therapeutic Goods Australia. I accept that any risks of using any nicotine products are my own and will keep any nicotine products out of reach of children and adolescents to prevent accidental poisoning. QuitRX is also not responsible for any issues at Customs & Australian Border Force. I understand that amendments after 24 hours of the prescription being sent will incur additional costs, and any amendments after 4 weeks will require a new submission and payment. Full refunds are only permitted if a cancellation request is sent prior to doctor review and communication. If we cannot fulfil the service for any reason, a 50% refund may be applicable. Otherwise refunds are not permitted after the service has been completed. I consent to QuitRX contacting me by telephone, email or SMS.
I consent to treatment and agree to the above declaration statement*

Yes
Purchasing Prescription Products for someone else using my prescription is illegal and an offense. I declare that I am obtaining a prescription for my own personal use, or if completing on behalf of someone else, the details reflect the patient and they have consented to this.*

Yes
If further information is needed, what is your contact preference? Note: Phone contact will take 1-3 business days.*

Telephone: I prefer a phone call by the doctor in the next 1-3 business days.Email: I prefer to be contacted by email (new patients may still be contacted by phone)No preference
RESEARCH QUESTIONS
How did you hear about QuitRX? (Select any that apply)*

Word of Mouth (family/friends/colleagues)PharmacyGP or Other Healthcare ProfessionalGoogleRedditFacebook or other social mediaNicotine pouch websites or suppliersOther
Please write any questions or further comments here (if there was any issues with uploading files or initial issues with the form let me know too):
Leave blank if no comments, but we also love to hear about your quitting journeys so please feel free to tell us your story! :)
To verify your identity and age, please upload your drivers license or proof of age card/passport

If you have trouble uploading documents, please upload a random picture (I always welcome photos of your pets!) and email a copy of your documents to hello@quitrx.com.au.

Assessment Fee*

Doctor AssessmentIncluding up to 12 month prescription

$85.00AUD

Total

$0.00AUD

Credit Card

Please upload Proof of Age card or Drivers License or Passport. If you are uploading a Drivers License, please attach photos of both sides. Please be aware that falsifying documents is a criminal offence.*

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PAYMENT FOR PRESCRIPTION

Note: Due to the importation laws and limits, the prescription usually includes 1 x 3 month supply and 3 repeats for 12 months supply. You can purchase lesser amounts, more frequently as long as the 3 month supply is not exceeded. For pharmacy prescriptions, this will be a monthly supply x 5 repeats for 6 month supply.
**NOTE: Please make sure you press the submit button once and wait. After a few seconds, if the form submission is successful, you will be taken to a 'thank you' page and receive an email confirmation. Any issues please contact hello@quitrx.com.au
PLEASE NOTE:

Please contact me (Dr Shu) at hello@quitrx.com.au if there are any issues with submitting the form - I can't fix issues I don't know about!

There are sometimes issues with browsers not allowing the submission (stuck 'please wait'), if you have issues please refresh the page, clear browser cache, or try a different browser or device. Thanks for your patience!

©2021 QuitRX
Should be Empty:

Medical Questionnaire

New or Repeat Assessment Declaration

Residential Address

Age and Intention Declaration

SMOKING HISTORY

OTHER MEDICAL HISTORY AND RISK FACTORS DECLARATION

NICOTINE POUCH USAGE HISTORY

CONSENT AND DECLARATION - PLEASE READ

RESEARCH QUESTIONS

To verify your identity and age, please upload your drivers license or proof of age card/passport

Credit Card

PAYMENT FOR PRESCRIPTION