Smoking Review

If you have been advised by the surgery to submit a smoking review on a regular basis please use this form.

Required field(s) are indicated by *
Smoking Review

Smoking Review

About you

First Name(s) as appears on your passport.

Last Name(s) as appears on your passport.

The one used to register with your GP.

Your date of birth is required to verify your identity.

As on your medical record.

The practice may use this number to contact you about your request.

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Please continue completing the form below

Smoking Review

Do you currently smoke?
*
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