Treatment Questions | Pharma Aesthetics

Answer medical questions to order

Have you read the medical information section?

Yes No

Have you been diagnosed with renal (kidney) disease?

Yes No

Not including occasional urine infection.

Are you pregnant or breastfeeding or planning to become pregnant whilst taking Champix?

Yes No

Have you been diagnosed with a psychiatric disorder or suffer from depression?

Yes No

Minor brief episodes of depression not included.

Are you aware Champix should be stopped if agitation, depressed mood, or changes in behaviour are causing concern?

Yes No

A small number of people experience agitation, depressed mood or changes in behaviour whilst taking Champix. If these occur Champix should be stopped.

Are you aware people not already taking Champix, should order a 2 week starter pack first (to build up dose)?

Yes No

People not already taking Champix should order a 2 week starter pack first (to build up dose).

Do you have any further medical information or questions?

Yes No

Is there anything you do not understand or do you need further help?

Do all the following apply to you?

Yes No

The tablets are for my own use and I will not share my medication with anyone else I will read the patient information leaflet supplied with my tablets I am over 18 and I agree to identity verification checks I have completed this questionnaire myself and fully understand all the information My responses are honest and accurate, and I understand that this is necessary for a safe medical assessment I agree to the terms & conditions, privacy policy, data sharing policy & consent to cookies.

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