NoCigs booking form

Book Consultation

Medicare

Do you have a Medicare card? *

YesNo

Do you use a different name in your Medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare first name

Medicare surname

Medicare card no. *

Medicare reference no. *The reference number is the number next to your name on your Medicare card.

Medicare expiry *

If eligible for Medicare, DVA or concessional billing do you give permission to bill? *

YesNo

I assign my right to benefits to the health professional who rendered the services. *

YesNo

Request Type

I am after *

Initial consult - $49.99*Follow up treatment plan - Bulk Billed to eligible Medicare Card Holders

You must have had a consultation with a healthcare professional first.

Bulk billed *

Initial consult - bulk billedFollow up treatment plan - Bulk Billed to eligible Medicare Card Holders

You must have had a consultation with a healthcare professional first.

*Out of pocket expense. Medicare rebates based on item# and HCP.

Private - No Medicare Card: $49.99 - out of pocket.

Follow up consultation- Bulk Billed

Private - No Medicare Card: $49.00 - out of pocket.

Appointment date and time *

Select a Service

Patient Details

First name *

Last name *

Preferred name

Date of birth *

Gender

MaleFemalePrefer not to say

Patient Contact Details

Mobile phone *

Email *

Address *

Postcode *

City / Suburb

State

Special Requests

Please provide us with any current medications, treatment options you are currently using

Smoking History

Are you 18+? *

YesNo

You must be 18 years or over to purchase vaping products. We are unable to provide a prescription for Nicotine.

Are you currently using a vaping device? *

YesNo

Nominate your supplier here:

What brand are you currently using?

What is your current nicotine strength ordered?

How old were you when you started smoking?

How many cigarettes do you smoke on a daily basis?

How long have you been a regular smoker?

How soon after you wake up, do you crave your first cigarette?

When was the last time you tried to quit smoking before?

Previous 12 months1-5 years ago

Have you ever consulted with a Healthcare professional to discuss your desire to quit smoking

YesNo

Health History

If you are currently taking medication, please list here:

Do you have a history of blood pressure? *

YesNo

Do you have any allergies? *

YesNo

Please list your allergies:

Have you had a heart attack, stroke or other cardiovascular concerns recently? *

YesNo

Do you have any of the following medical conditions? *

Lung diseaseHeart diseaseMental healthNo

Are you pregnant, or likely to become pregnant? *

YesNo

If so, are you breastfeeding?

YesNo

Consent

We are committed to protecting your privacy and know it is important for you to understand how your information is handled.

In submitting the information contained in this form, you:

Consent to collection of personal information and NoCigs Privacy Policy *

Acknowledge that your health practitioner will collect such information (including any personal or sensitive information), for the purposes of providing you with health services or enabling any related communications. *

Payment

Please complete the following payment prior to submitting your form *

Signature

I confirm that above information I have provided is true, complete and accurate. *

Signature

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