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.
If you don't provide an email address we won't be able to respond to you by email

Smoking Review

Do not currently smoke section

Do currently smoke section

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

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