Smoking Review

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Personal Details

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

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Smoking Review

Do you currently smoke?: *

How many cigarettes do you smoke in a day?: *

Would you like to give up smoking?: *

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

Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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