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.

Smoking Habits

Do you smoke?
Would you like to see the Smoking Cessation Nurse?
Are you currently taking any replacement therapy?

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

Sending