Simple Online Doctor

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1Your smoking history

READ >>> Top tips for stopping smoking.

How long have you been smoking or vaping? *

How often do you smoke a day? *

What strength of nicotine do you vape and how often? *

Do you have any known allergy to Varenicline or Zyban (bupropion)? *

NoYes

Please provide more information below. *

Are you taking any other products to help you stop smoking? *

NoYes

Please list the other products you are using to help you stop smoking, including the strength/ dose. *

Please confirm that you will stop using any nicotine replacement products (eg patches, gum, inhalator) and any other treatments to stop smoking before you start using Varenicline or Zyban (bupropion). *

Confirm

Are you currently taking Zyban or Varenicline *

NoYes

Please confirm your current dose: *

2Your health

Do you currently have or have you ever had one of the following ? Select all that apply: *

A psychiatric disorder such as depression, anxiety, panic attacks or bipolar disorderAny problems with your liver or kidneysA central nervous system (brain) tumourundergoing abrupt withdrawal from alcohol or medication such as benzodiazepines (eg diazepam, zopiclone, temazepam)An eating disorder such as bulimia or anorexia nervosaA history of alcohol abuseHigh blood pressure or are currently being treated for high blood pressureNone of the above

Do you have any of the following conditions?

History of seizures/epilepsy
Diabetes
Heart disease/stroke
Head trauma
Any serious medical condition which may require immediate hospitalisation
History of skin reactions like Steven Johnson's syndrome

NoYes

Please provide more information below. *

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? *

NoYes

Please list any prescription, over the counter or alternative medicines you are taking, including the dose. *

Are you currently taking any of the following medicines?

Antidepressants (such as citalopram, sertraline, fluoxetine, venlafaxine) or MOAI’s (Monoamine oxidase inhibitors, such as phenelzine, selegiline)
Antipsychotics (such as quetiapine, haloperidol, lamotrigine, clozapine)
Epilepsy medication (such as carbamazepine, phenytoin, valproic acid)
Antimalarials (such as mefloquine, malarone, chloroquine)
Theophylline
Oral steroids (such as prednisolone)
Antibiotics such as Ciprofloxicin/Levofloxacin
Antihistamines (Such as chlorpheniramine (Piriton), hydralazine)
Heart medication such as beta blockers, digoxin or propafenone
Medication to treat Parkinson’s (such as levodopa or amantadine)
Warfarin
Erlotinib

NoYes

Please provide more information below. *

Are you currently pregnant, planning to become pregnant or breastfeeding? *

NoYes

Please provide more information below. *

3Consent

If you experience any of the following when taking Zyban (Bupropion) or Champix (Varenicline) you should stop treatment and seek urgent medical help immediately: Thoughts of self harm, depression or mood changes and or unusual changes in behaviour *

Confirm

Please confirm you understand the following; You will stop Varenicline or Zyban and contact your GP if you develop agitation, low mood or think you might be experiencing depression **** If you develop swelling of the face, mouth or neck **** if you develop Seizures

Confirm

I understand that lower doses are used first to build up tolerance before increasing the dose as directed. ***I am aware that I still need to exercise will power to stop smoking *** *

Confirm

I understand I should start treatment 1–2 weeks before target stop date. I understand the dose of Zyban (bupropion) for stopping smoking for under 65s is ONE daily for the first 6 days followed by ONE twice a day from day 7 for a maximum of 9 weeks, or if over 65 the dose is ONE daily for a maximum of 9 weeks. I understand that I should discontinue if abstinence not achieved at 7 weeks. *Please confirm even if you intend to request Varenicline* *

Confirm

I agree not to take other products that contain bupropion at the same time as Zyban. *Please confirm even if you intend to request Varenicline* *

Confirm

I confirm I am over 18 years old.

The medicine ordered is for my sole use only.

I will read the consumer medicine information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.

I agree to the Simple Online Doctor terms and conditions. *

Confirm

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf? If you are unsure, you can search your GP clinic information by clicking here.

NoYes

Please enter the email address of your GP clinic *

As per Australian telehealth guidelines, all first time patients, those requesting a new treatment or those looking to renew a prescription must have a brief video or phone call with one of our doctors. Do you have reliable access to the internet on a device which you can use to have a video conversation with our doctors? *

NoYes

You require reliable access to the internet on a device which you can use to have a video consultation with the doctor in order to be suitable for telehealth. Please refer to your regular GP in person.

During your consultation, our doctor will assess whether you are suitable for treatment. If you are, a prescription will be provided to and filled by our pharmacy partner and delivered to your chosen address. Any and all resupplies will be stored on your account and will be available for request from our service when required. For resupplies you will only need to pay for the medication and shipping, you will not be charged a consultation fee. Please confirm you understand this information. *

Confirm

If we are unable to assist via a telehealth consultation, you may be asked to seek alternative medical care such as that of a doctor in person. If this occurs you will receive a refund on your request.

Simple Online Doctor is a private clinic; the consultation and medication may be eligible for rebates through your private health cover, but are not covered by Medicare or the PBS. We conduct regular price reviews to ensure we are providing among the best value online.

Did you have difficulty understanding the English that is written in this assessment, affecting your ability to provide accurate answers or do you require language interpretation during a verbal consultation? *

NoYes

As you have difficulty understanding the assessment and or require interpretation services, you will be required to have an interpreter with you during your consultation with the doctor. You can access these services at Translating and Interpreting Services. Please confirm that you agree to organise an interpreter for your consultation.

Confirm

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Assessment

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2Your health

3Consent

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