By submitting this form, I declare that all information is true and accurate. I have read the terms and conditions, and privacy policy on the website. I confirm that I am the legal owner of the medicare details provided and understand that providing false or inaccurate information may be a criminal offense or misusing someone else's identity constitutes identity fraud. I understand that all information is confidential, and may be used by third parties for authorised identity verification purposes only. I understand that nicotine is an addictive substance with potentially harmful effects to users or bystanders, and its short or long term effects are largely unknown. I am aware that there are currently no products registered or approved by Therapeutic Goods Australia. I accept that any risks of using any nicotine vaping products are my own and will keep any nicotine products out of reach of children and adolescents to prevent accidental poisoning.
CONTACT: I consent to QuitRX contacting me by telephone, email or SMS.
AMENDMENTS: I understand that amendments within 4 weeks of the prescription being sent will incur a $25 amendment fee. I understand that QuitRX is not responsible for any product strength/formulation changes that require new prescriptions.
PAYMENT: I consent to making payment in full, and have the cardholder authority to make payment.
REFUND POLICY: Full refunds are only permitted if a cancel request is sent prior to doctor review and contact. No refunds are given once the assessment has been reviewed by the doctor, or if the service has been completed and prescription has been sent.
DISCLAIMER: QuitRX is not affiliated with any nicotine vaping brands or companies and does not endorse specific brands or products.
