Smoking Review

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

Smoking Review

Smoking Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Smoking Review

Smoking Status *
Would you like smoking cessation advice?

Do not currently smoke section

How many cigarettes do / did you smoke in a day?

Do currently smoke section

Would you like smoking cessation advice? *
*

Please ask at reception for more information about giving up smoking.