Stop Smoking

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What state do you live in?
First, we need to make sure we are licensed in your state.
What state do you live in?*
Unfortunately we cannot service this condition in your state. Please contact your local physician for assistance.
Your state may require a phone or video consultation to complete your treatment. Don't worry! Your doctor will reach out to you if this is the case.

What is your first and last name?
Name*

First NameLast Name

What is your email?
What is your email?*
example@example.com
Type a question*

By Checking Here… You agree to receive doctor correspondence，transactional and/or marketing messaging from MetaHealthRX，to the email address that you provided above.

What is your phone number?
Please enter the best phone number to reach you on just in case the doctor has any questions regarding your medical information.
Phone Number*
Please enter a valid phone number.
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What is your date of birth?
Birth Date*

MonthDayYear
You must be 18 to order this prescription medication.
today*

MonthDayYear
Date
age*

What is your gender?
What is your gender?*

MaleFemale

Are you currently taking any prescription or over-the-counter medications / vitamins / minerals / supplements?
Are you currently taking any prescription or over-the-counter medications / vitamins / minerals / supplements?*

YesNo
currTakingMeds-IMP
Please list which medications.
Please list which medications*
Many medications interact with Stop-Smoking medications. Your doctor wants to be sure of every medication you take. Are you SURE you do not take any other medications?
Yes: I affirm, I do NOT take any other medications.*

Yes: I affirm, I do NOT take any other medications.

What types of nicotine do you use?
What types of nicotine do you use?*

CigarettesE-cigarettes (Vape pens)Chewing tobaccoCigarsOther
What other nicotine do you use?
What other nicotine do you use?*

Have you previously tried to quit smoking?
Have you previously tried to quit smoking?*

YesNo
How many times have you tried to quit smoking?
How many times have you tried to quit smoking?*
When did you last attempt to quit?
When did you last attempt to quit?*

Within the last yearMore than a year ago
How long were you able to go without smoking?
How long were you able to go without smoking?*

What medication or treatment have you tried when quitting?
What medication or treatment have you tried when quitting?*

Nicotine replacement such as gum or patchesOral medicationsTried quitting without medication or treatmentOtherI have not previously tried to quit
takenMedsAndTreatments-IMP
What medication or treatment did you take? Did you find the treatment effective?
What medication or treatment did you take? Did you find the treatment effective?*
Did taking nicotine replacement cause any side effects?
Did taking nicotine replacement cause any side effects?*
What medication did you take? Did you find the treatment effective?
What medication did you take? Did you find the treatment effective?*
whatMedicationTried-IMP
Did taking oral medication cause any side effects?
Did taking oral medication cause any side effects?*
oralMedsSideEffects-IMP
Please provide details on what other methods you have tried.
Please provide details on what other methods you have tried.*
experiencingSymptoms-IMP*
none_1*
Please uncheck 'I have not previously tried to quit' if you have selected any other options.
Please uncheck 'Tried quitting without medication or treatment' if you have selected any other options.

Do you have, or have you ever had any of the following medical conditions?
Do you have, or have you ever had any of the following medical conditions?*

AnxietyBipolar disorderDepressionHistory of suicidal attemptsMood or mental health disorderSchizophreniaNone
Please provide more details on your anxiety condition.
Please provide more details on your anxiety condition.*
Please provide more details on your depression condition.
Please provide more details on your depression condition.*
detailsPastConditions_anxiety-IMP
detailsPastConditions_dep-IMP
medConditions-IMP
none_2*
Please uncheck 'None' if you have selected any other options.

We are sorry we cannot help you. This treatment plan does not apply to you.

How often do you consume alcoholic beverages?
How often do you consume alcoholic beverages?*

NeverMonthly or less2 to 4 times a month2 to 3 times a week4 or more times a week
amountOfAlcoholicBeverages-IMP

We are sorry we cannot help you. This treatment plan does not apply to you.

Have you been diagnosed with or experienced any of the following?
Have you been diagnosed with or experienced any of the following?*

Uncontrolled hypertension (greater than 160/100mmHg)Seizures (does not include seizures only when a child)Eating disorderNeurological disorderGlaucomaKidney diseaseCirrhosis or liver failureOtherNone
Please provide additional details regarding neurological disorder.
Please provide additional details regarding neurological disorder.*
Please list all medical conditions you have.
Please list all medical conditions you have.*
conditionDetails_neuro-IMP
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diagnosisAndExps-IMP
none_3*
Please uncheck 'None' if you have selected any other options.

We are sorry we cannot help you. This treatment plan does not apply to you.

Are you currently taking any prescription medication now to quit smoking?
Are you currently taking any prescription medication now to quit smoking?*

YesNo
Please list which medications you are taking.
Please list which medications you are taking.*
is_curr_taking_smoking_meds-IMP
curr_taking_smoking_meds_list-IMP

Do you have a preferred medication you want to try to help you quit?
Do you have a preferred medication you want to try to help you quit?*

YesNo
Please note your preferred medication.
Please note your preferred medication.*
preferredMed-IMP
preferredMedication-IMP

How often do you smoke per day?
How often do you smoke per day?*

10 or fewer11 to 20More than 20

Have you experienced any of the following when previously trying to quit?
Have you experienced any of the following when previously trying to quit?*

AnxietyDepressionInsomniaNoneOtherI haven’t tried to quit
What else have you experienced?
What else have you experienced?*
none_4*
Please uncheck 'I haven’t tried to quit' if you have selected any other options.
Please uncheck 'None' if you have selected any other options.

Does any of the following apply to you?
Does any of the following apply to you?*

I am pregnantI am breastfeedingI am planning on getting pregnant in the next 6 monthsNone
preg-IMP
none_5*
Please uncheck 'None' if you have selected any other options.

Have you experienced any of the following in the past 6 months?
Have you experienced any of the following in the past 6 months?*

FeversNight sweatsDifficulty speaking or swallowingCoughing up bloodUnexplained weight lossNone
expLast6Months-IMP
none_6*
Please uncheck 'None' if you have selected any other options.

Do you have known drug allergies, or other allergies?
Do you have known drug allergies, or other allergies?*

YesNo
Please list all known allergies or intolerances.
Please list all known allergies or intolerances.*

How long ago was your most recent check up with a physician?
How long ago was your most recent check up with a physician?*

Within past yearWithin 2 yearsWithin 3-5 yearsOver 5 years ago

Did you understand all the questions which were asked?
Did you understand all the questions which were asked?*

YesNo
understandQuestions-IMP*
Which question did you not understand?
Which question did you not understand?*
whichQuestion-IMP*
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Here's your first message to your doctor.
Please introduce yourself and feel free to:
- Ask any questions you have
- List any medical problem you have which were not discussed above
- Include anything else you would like the doctor to know.
Here's your first message to your doctor.*

0/0
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Please acknowledge that you understand and agree to the following:

I have filled out a medical intake form that will be used by a board certified physician that is licensed in my state to make a medical treatment plan for me. I understand all the questions that have been asked of me. The information that I have provided is accurate and complete. I am the patient who is consenting to be evaluated for treatment.
Please acknowledge that you understand and agree to the following:*

I acknowledge and agree to the above.

Medication we offer:
Bupropion*

Bupropion SR (Zyban) 150mg
Quantity of 180, billed and shipped quarterly (every 3 months)for $45.
productRequested
sku*
Should be Empty:

What state do you live in?

What is your first and last name?

What is your email?

What is your phone number?

What is your date of birth?

What is your gender?

Are you currently taking any prescription or over-the-counter medications / vitamins / minerals / supplements?

What types of nicotine do you use?

Have you previously tried to quit smoking?

What medication or treatment have you tried when quitting?

Do you have, or have you ever had any of the following medical conditions?

We are sorry we cannot help you. This treatment plan does not apply to you.

How often do you consume alcoholic beverages?

We are sorry we cannot help you. This treatment plan does not apply to you.

Have you been diagnosed with or experienced any of the following?

We are sorry we cannot help you. This treatment plan does not apply to you.

Are you currently taking any prescription medication now to quit smoking?

Do you have a preferred medication you want to try to help you quit?

How often do you smoke per day?

Have you experienced any of the following when previously trying to quit?

Does any of the following apply to you?

Have you experienced any of the following in the past 6 months?

Do you have known drug allergies, or other allergies?

How long ago was your most recent check up with a physician?

Did you understand all the questions which were asked?

Here's your first message to your doctor.

Medication we offer: