Title

First Name *

Last Name *

DOB *

Phone Number *

Email Address

Address *

Suburb *

Postcode *

State *

Medicare number

What number are you on your Medicare card?

If you do not have a Medicare card, you will be charged as a private patient, $40 per script.

Is this your first script for vaping or a repeat? *

First Repeat

Vaping is now a second line treatment that doctors can recommend to help you quit smoking. This means that you need to have tried to quit with other smoking cessation methods before we can issue a prescription. Please select which products you have used in the past: *

Once you submit this form, the Quit Vaping Scripts team will call your mobile to confirm details.

If you do not have a Medicare card, you will be charged as a private patient, $40 per script.

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