TAX INVOICE Voucher for Nicotine Replacement Therapy Quit for new life Program Health worker to complete Dear Pharmacist, is receiving support to quit smoking as part of the Quit for new life Program. Client is pregnant / breastfeeding Client is in the postnatal period or or LY Client is a cohabitant who lives with a pregnant / postnatal woman He/she smokes their first cigarette within meets the definition of ‘nicotine dependent’. minutes of waking and smokes ___ cigarettes daily, which N I have recommended Nicotine Replacement Therapy (NRT) to assist with client/cohabitant’s quitting. O I have discussed NRT options with the client. The client prefers to use _______________________ Please assess and if deemed suitable, provide an appropriate NRT product. Redeem for: 2 weeks 6 weeks 8 weeks 10 weeks 12 weeks supply Tel PL E Health worker’s name 4 weeks Job title _______________________________Local Health District _______________________________ Signature Date No M Client Record Number or DOB____________________ Previous voucher/s provided? Yes Pharmacist to complete SA Pharmacy name ABN EFT Details: BSB Email / Acc No. Tel Address Date of issue of product / / _ Name, dosage and quantity of product supplied Total Retail Price (including GST) $ Full name of client: Full name of Pharmacist: Signature of client: Signature of Pharmacist: Give a copy of this form to the client and retain the original for your records Pharmacist: See overleaf for payment details and notes on NRT TAX INVOICE Payment details (for pharmacist) To enable payment: Please FAX this form within 5 days to: Pharmacy Guild of Australia, NSW Branch Fax: 02 9467 7151 Payment will be made by Electronic Funds Transfer (EFT) N Notes on NRT for pregnant and breastfeeding women: LY For enquiries about vouchers payments: Please call the Health Services Manager, Pharmacy Guild of Australia, NSW Branch Ph.9467 7140 For enquires about the Quit for new life program: Please contact the Statewide Coordinator, Rhonda Matthews on [email protected] or 9391 9951 PL E O The Quit for new life program is a NSW Health initiative supporting pregnant Aboriginal women (and their families) to quit smoking. Up to 12 weeks free supply of NRT is available to each woman and their household members (if clinically appropriate). NRT is recommended for nicotine dependent pregnant and breastfeeding women where the likelihood and benefit of quitting outweighs the potential harm of NRT and continued smoking. Intermittent NRT is preferred as it more closely mimics nicotine levels from smoking. However, where intermittent NRT is not tolerated, patches may be used (as per Therapeutic Guidelines: Psychotropic drug use in pregnancy: non-prescribed psychoactive drugs). Pregnant women need to be made aware of the need to remove patches at night to provide an 8 hour break. Up to 12 weeks supply in total can be redeemed at the one time using one voucher. The lowest cost product should be supplied. Guidance on NRT dosages for pregnant women: Dosage M NRT Self titrate dose according to withdrawal symptoms When used as a single therapy: 8-12 gum/day One gum should be chewed slowly until the taste becomes strong (1 minute). Then stop and rest the soft gum against cheek. When taste fades chew a few more times until taste gets stronger. Use 20 to 30 minutes per gum, then discard. Pregnant women will usually require 4mg gum No eating or drinking while gum is in mouth. Self titrate dose according to withdrawal symptoms. When used as single therapy: 9-15 lozenges/day One lozenge placed in the mouth, periodically moved from one side of the mouth to the other until dissolved (20-30 minutes). The lozenge should not be chewed or swallowed whole. No eating or drinking while lozenge is in mouth. SA Gum Lozenges Pregnant women will usually require 4mg lozenge Inhalator Patch Directions for use Self titrate dose according to withdrawal symptoms. When used as single therapy: 6-12 cartridges/day Insert cartridge, close device to puncture. Inhale air through device. Nicotine is absorbed through oral mucosa. 10 or more cigarettes/day, more than 45kgs: one 21mg/24hr or 25mg/16hr patch daily Do not use on adhesive-sensitive skin. Place on clean, nonhairy site anywhere on non-fatty parts of the body. A new patch should be placed on a different site each day to help prevent a skin reaction. If body weight is less than 45kgs: offer inhaler, lozenge or microtab. Medical Officers (MO) may prescribe 14mg patches to women less than 45kgs. Pregnant women should remove the patch before sleeping and apply a new patch in the morning. Note: Quit for new life clients are only eligible for one form of free NRT at a time through Quit for new life.
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