Request a prescription

Title

First Name *

Last Name *

DOB *

Phone Number *

Email Address

Address *

Suburb *

Postcode *

State *

Medicare number

I assign my right to benefits (Medicare or out of pocket) to the health professional who rendered the services. *

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

FirstRepeat

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: *

I understand that e-cigarette nicotine is an "unapproved product" according to the TGA. *

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

For security please complete the check below *