Smoking - Checkout Page

Please answer a few medical questions from our practitioner to prescribe your medication.

Please note: If you need urgent assistance, do not use this service. Call 111, or in an emergency call 999.

Are you a male or female?
(Biological assigned gender at birth)

Male Female

What is your height?

What is your weight?

What is your blood pressure?

What is your date of birth?

Do you smoke?

Yes No

How many cigarettes do you smoke per day?

Have you had any cardiovascular(heart) problems or have you ever had a stroke?

Yes No

Can you walk 3 miles without pain in your chest?

Yes No

Do you suffer from any allergies?

Yes No

Please detail any allergies that you may have.

Are you currently taking any other medication, or have recently finished a course of medication?

Yes No

Medication name

Strength
(e.g. 100mg. If unsure, type: 'I'm not sure'.)

How many do you take a day?
(e.g. 1 tablet twice a day)

Select file / image

Is there a history of any disorder that has run within your family?

Yes No

Please provide more information, including as much detail as possible.

Have you ever had any major surgery?

Yes No

Please provide more information, including as much detail as possible.

Do you believe you have the mental capacity to make decisions about your own healthcare?

No Yes

You have selected you do NOT have mental capacity to make decisions about your own healthcare please provide further information, including as much details as possible

Do you agree to give consent for PrescriptionDoctor.com’s prescribers and/or pharmacist to access your summary care record (SCR)?

Yes No

Your Treatment

Are you currently registered with a UK GP practice?

Yes No

Would you give us permission to speak to your doctor if we need to discuss your treatment and to keep them informed about any medications prescribed for you?

Yes No

Can you tell us why you are not currently registered with a GP, or why you're unsure? Please remember that you must make sure to provide GP details next time, otherwise we might not be able to accept your order request.

I've only recently moved to the UK I've been removed from my practice list and not had a chance to register elsewhere Other

Do you agree that you have answered all of the above questions accurately and truthfully. You understand our prescribers will prescribe medication based on your responses, any incorrect responses or deliberate acts to misinform may be hazardous to your health. You are happy for your consultation to be reviewed by a Pharmacist Independent prescriber.

I agree

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