Medical Questionnaire

- If you can't remember, select "No" - If you have used We Can Quit before, many questions will change, but as product usage may change over time, we will need to ask this again

You must be 18 or over to use this service

No mail will be sent here. This is a requirement for medical services.

if you do not have an IHI you can apply for one via this link get your IHI number

All medical guidelines strongly discourage use of nicotine for vaping 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 or vaping outside of previous tobacco use. Nicotine Vaping Products (NVPs) 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.

Vaping is not first line treatment for smoking cessation. It can be considered after first line treatments (including behavioural support):

-Cold Turkey
-Hypnosis/Psychologist counselling
-Nicotine patches/gum/spray
-Doctor prescribed Varenicline (Champix)
-Doctor prescribed Bupropion (Zyban)
-Other

Please write "none" if you don't have any

We do not prescribe products owned by Big Tobacco, or ingredients for mixing.

Leave blank if you don't have one

If you're not sure, write 'not sure' and we will discuss appropriate products

Your intake will be reviewed by our doctor after assessment by our We Can Quit nurse team. A prescription will be issued within 1–2 business days, with the option for a consult if you’d like or if medically needed. This is often faster during quieter periods.

I declare that all information is true and accurate. I have read the terms and conditions, and privacy policy on the website. 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 currently no products registered or approved by Therapeutic Goods Australia. I accept that any risks of using any nicotine vaping products are my own and will keep any nicotine products out of reach of children and adolescents to prevent accidental poisoning.

CONTACT: I consent to We Can Quit contacting me by telephone, email or SMS.

AMENDMENTS: I understand that amendments within 4 weeks of the prescription being sent will incur a $25 amendment fee.

REFUND POLICY: Full refunds are only permitted if a cancel request is sent prior to doctor review and contact. Partial refunds are permitted if no prescription is sent. No refunds are given once the service has been completed and prescription has been sent.

DISCLAIMER: We Can Quit is not affiliated with any nicotine vaping brands or companies and does not endorse specific brands or products.

Purchasing Nicotine Vaping 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.

I declare that all entries on this form are correct to the best of my knowledge.

We Can Quit - Registration Form

Sorry