Smoking Review




Please complete our online form

Your submission will not get looked at until the next working day of the surgery.

Page {{ paginatorProps.current }} of {{ }} ({{ paginatorProps.percentage }}% completed)
Personal Details

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

If you use Android device, please click on year to change it
Please double check you've entered the correct email address
May be used to identify you
Smoking Review

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

Privacy Consent

This form collects personal and medical information about you. 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.


Page you are trying to access does not exist.