Last Updated: 17/10/2022

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

Your Details

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Date of Birth Required
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Do you Smoke? Required
If 'Yes' How many cigarettes do you smoke in a day? Required
If 'No' Have you smoked in the past? Required
IF 'YES' HOW MANY CIGARETTES DID YOU SMOKE IN A DAY? Required

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. 

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