Varenicline for Smoking Cessation

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Consultation

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To find a treatment suitable for you, we just need you to answer a few questions.

Hussain Member
Superintendent Pharmacist

Confidential & Secure

We will review your details in complete confidence

Medication will be delivered in plain unlabelled packaging

Your order will appear on your statement as "My Chemist Plus"

General
Pharmaceutical
Council

General Pharmaceutical Council

My Chemist Plus is registered and regulated by the GPhC, who are the official body that regulates and inspects all pharmacies in the UK.

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LegitScript certification

My Chemist Plus is certified by Legit Script, who monitors online pharmacies to evaluate compliance.

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Need help?

If you need help with this medical assessment, contact our helpline:

01204 806059

or email us

admin@mychemistplus.co.uk

Eligibility

Consent(Required)

I confirm that I am seeking this medication to help me stop smoking as part of a planned quit attempt. I understand that varenicline is not suitable for emergency use, acute nicotine withdrawal management, or recreational purposes. I am not currently experiencing a mental health crisis, suicidal thoughts, or self-harm urges. If I am, I will contact 999, NHS 111, or the Samaritans (116 123) immediately instead of completing this form.(Required)

Are you aged between 18 to 75 and smoke tobacco based products?(Required)

Yes

A supply of medication cannot be made, please contact your GP for further help and information. Thank you.

Are you pregnant, breastfeeding, planning a pregnancy, or think you might be pregnant?(Required)

Yes

A supply of medication cannot be made, please contact your GP for further help and information. Thank you.

Have you ever had an allergic reaction to varenicline (Champix) or any of its ingredients?(Required)

Yes

A supply of medication cannot be made, please contact your GP for further help and information. Thank you.

Have you ever been diagnosed with or treated for any mental health condition (e.g., depression, anxiety, bipolar disorder, schizophrenia, PTSD, eating disorder)?(Required)

Yes

A pharmacist will contact you to discuss if this treatment is suitable for you.

In the past 3 months, have you experienced suicidal thoughts, self-harm urges, a psychotic episode, or been admitted to a psychiatric unit?(Required)

Yes

A supply of medication cannot be made, please contact your GP for further help and information. Thank you.

Do you have a current dependency on benzodiazepines, opioids, or other substances (excluding nicotine), or a history of overdose within the last 2 years?(Required)

Yes

A pharmacist will contact you to discuss if this treatment is suitable for you.

Medication & History

Do you have, or have you ever had, ANY of the following?(Required)

Kidney disease

Seizures or epilepsy

Heart disease or stroke

Diabetes

Any serious medical condition under hospital or specialist care

Any condition currently under hospital or specialist care

None of the above

A pharmacist will contact you to discuss if this treatment is suitable for you.

Do you suffer with any medical conditions?(Required)

Yes

Please detail any conditions you have:(Required)

Are you taking any medicines, herbal products, or supplements?(Required)

Yes

Please detail what you are taking, letting us know how often and dosing where possible:(Required)

Are you currently taking any of the following medicines? (tick all that apply)(Required)

Clozapine

Olanzapine or other antipsychotics

Theophylline or aminophylline

Warfarin or other anticoagulants

Insulin

Methadone

Ropinirole

Flecainide

None of the above

A pharmacist will contact you to discuss if this treatment is suitable for you.

Understanding the Medication

Concent(Required)

I understand that I must stop varenicline and seek urgent medical help immediately if you develop: mood or behaviour changes, agitation, suicidal thoughts, seizures, chest pain, breathing difficulty, severe rash, or swelling of face/lips/tongue.(Required)

Concent(Required)

I understand that stopping varenicline may cause irritability, stronger urges to smoke, low mood, or insomnia in up to 3% of patients. Your prescriber may recommend gradual dose reduction.(Required)

Do you understand that:

• Varenicline is started 1–2 weeks BEFORE your planned quit date
• You begin with a low-dose starter pack (Days 1–3: one 0.5mg tablet daily; Days 4–7: one 0.5mg tablet twice daily)
• From Day 8 onwards: one 1mg tablet twice daily • The full course is 12 weeks
• You must set a quit date and commit to stopping smoking on that date

Concent(Required)

Yes, I understand the above.(Required)

Smoking History

How many cigarettes do you smoke per day on average?(Required)

Please enter a number from 1 to 100.

How soon after waking do you smoke your first cigarette?(Required)

Within 5 minutes

6–30 minutes

31–60 minutes

After 60 minutes

Have you tried to quit smoking before?(Required)

Yes

No, this is my first quit attempt

Please describe what you used and what happened:(Required)

Declerations and Consent

Are you motivated to stop smoking and committed to setting a quit date within 1–2 weeks of starting this medicine?(Required)

Yes

A supply of medication cannot be made, please contact your GP for further help and information. Thank you.

Are you willing to use behavioural support alongside this medicine (e.g., NHS Smokefree app, telephone helpline, family/friend support, or local stop-smoking service)?(Required)

Yes

A supply of medication cannot be made, please contact your GP for further help and information. Thank you.

How would you describe your alcohol consumption?(Required)

I do not drink alcohol

I drink within recommended limits (≤14 units per week)

I drink above recommended limits (>14 units per week)

I have a history of alcohol dependency or am currently in recovery

A pharmacist will contact you to discuss if this treatment is suitable for you.

Do you drive or operate heavy machinery as part of your daily routine or employment?(Required)

Yes — I understand I must not drive or operate machinery if I experience dizziness, drowsiness, or loss of consciousness while taking varenicline

Yes but I do not agree to this restriction

A supply of medication cannot be made, please contact your GP for further help and information. Thank you.

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Do you consent to us sharing the details of your supply with your regular GP in order to improve your continuity of care?

Yes

Please be aware of the importance for your GP to be informed of all of the medication you are taking to ensure that you receive the best care. Please only choose "No" if you are certain you do not wish for us to inform your GP

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Please provide Doctor Details

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Enter Surgery Name

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Please provide Doctor Details

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Please provide Doctor Details

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Please provide Doctor Details

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Please provide Doctor Details

Concent(Required)

I confirm this treatment is for my own personal use and my answers are honest and complete and I will read the Patient Information Leaflet before taking this medicine.(Required)

Consent(Required)

I understand the pharmacist will make the final decision for supply of this medication and may access my national care record to aid them to make a decision.(Required)

Consent(Required)

I understand this medication may reduce my tolerance to alcohol and I must ensure I do not experience dizziness or drowsiness before driving or operating machinery.(Required)

Consent(Required)

I understand that I should contact the pharmacy or seek medical help if I experience any concerning side effects.(Required)

Complete our 2 minute
questionnaire

Hussain Member
Superintendent Pharmacist

General
Pharmaceutical
Council

or email us

Eligibility

Medication & History

Understanding the Medication

Smoking History

Declerations and Consent

Contact Us

01204 806059

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Information

Online Pharmacy

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Complete our 2 minute questionnaire

Hussain MemberSuperintendent Pharmacist

General Pharmaceutical Council

or email us

Eligibility

Medication & History

Understanding the Medication

Smoking History

Declerations and Consent

Contact Us

01204 806059

Get To Know Us

Information

Online Pharmacy

Follow us:

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Hussain Member
Superintendent Pharmacist

General
Pharmaceutical
Council