We ask these questions to ensure that any medication prescribed is safe based on your biological sex and pregnancy status.
What was your sex assigned at birth?
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Are you currently pregnant, breastfeeding or planning to become pregnant?
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I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
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Smoking history
Smoking history
How long have you used tobacco products?
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Smoking history
Smoking history
On average, over the last 2 months, how much do you smoke on a daily basis?
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Smoking history
Smoking history
How soon after waking up in the morning do you smoke your first cigarette?
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Smoking history
Smoking history
How frequently do you experience cravings to smoke?
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Smoking history
Smoking history
Have you tried to quit smoking before?
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Side effects
Side effects
Did you experience side effects to this smoking cessation treatment
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Medical history
Medical history
Within the last year have you experienced severe depression, suicidal thoughts, and/or been admitted into a behavioral health institution?
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Please attest to the following confirming that all information you have provided to us is true and complete.
Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
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Please read the following IMPORTANT information to learn about the use of these products, including side effects.
Purpose of Treatment
Potential Benefits
Contraindications
Potential Risks and Side Effects
Monitoring and Follow-up
Alternative Treatments
Patient Responsibilities
Inform your provider of any changes to your health, medications, or lifestyle.
By agreeing below, you acknowledge that you have read and understood the information provided in this consent form. You agree to proceed with treatment under the conditions outlined above.
Purpose of Treatment
- Varenicline (Chantix): A prescription medication that reduces cravings and the reward effects of smoking by partially stimulating nicotine receptors and blocking nicotine's effects.
- Bupropion (Zyban): A prescription medication that reduces cravings and withdrawal symptoms by increasing dopamine and norepinephrine activity in the brain.
- Nicotine Replacement Therapy (NRT): Over-the-counter or prescription products (e.g., patches, gum, lozenges, inhalers, nasal spray) that deliver nicotine in controlled amounts to help reduce withdrawal symptoms and cravings.
Potential Benefits
- Reduces cravings and withdrawal symptoms.
- Decreases the likelihood of relapse.
- Improves overall quality of life by supporting smoking cessation.
Contraindications
- Varenicline:
- Known allergy or hypersensitivity to varenicline or its components.
- Use with caution in individuals with a history of severe psychiatric illness or unstable cardiovascular condition
- Bupropion:
- History of seizure disorders or eating disorders (e.g., bulimia or anorexia nervosa).
- Recent or current use of MAOIs or abrupt discontinuation of alcohol, sedatives, or benzodiazepines.
- Nicotine Replacement Therapy:
- Severe skin reactions (for patches) or hypersensitivity to nicotine or the product components.
- Caution in individuals with uncontrolled high blood pressure or recent cardiovascular events (e.g., heart attack or stroke).
Potential Risks and Side Effects
- Varenicline:
- Nausea, vivid dreams, insomnia, headache.
- Rare but serious side effects include mood changes, depression, and suicidal thoughts or behavior.
- Bupropion:
- Insomnia, dry mouth, headache, increased anxiety, or irritability.
- Rare but serious side effects include seizures (particularly at high doses or in those with risk factors).
- Nicotine Replacement Therapy:
- Skin irritation (patches), throat or mouth irritation (gum/lozenges), or nausea.
- Overuse can lead to nicotine toxicity (e.g., dizziness, rapid heartbeat).
Monitoring and Follow-up
- Inform your provider of any new symptoms, worsening conditions, or unexpected side effects.
Alternative Treatments
- Behavioral counseling or support groups.
- Gradual reduction strategies without medication.
- Other prescription medications as deemed appropriate by your provider.
Patient Responsibilities
- Take all medications exactly as prescribed.
- Report any side effects, adverse reactions, or new symptoms promptly.
- Attend follow-up appointments to monitor progress and adjust treatment as needed.
Inform your provider of any changes to your health, medications, or lifestyle.
By agreeing below, you acknowledge that you have read and understood the information provided in this consent form. You agree to proceed with treatment under the conditions outlined above.
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Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.
What you were seeking help for:
• Smoking Cessation
Why this happens
Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.
Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.
