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

Please do not complete this form unless you have been asked to do so by the surgery. 

About You

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

Smoking Review

Do not currently smoke section

Do currently smoke section

*

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