Smoking Review

Due to the current crisis we may take a little longer to deal with requests, we aim to deal with any queries as soon as possible, prescriptions and sick notes will be issued within 5 days and backdated where required.

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.
Any responses we send will go to this email address.

Smoking Review

Do you currently smoke?

Do not currently smoke section

Have you smoked in the past?
How many cigarettes did you smoke in a day?

Do currently smoke section

How many cigarettes do you smoke in a day?
Would you like to give up smoking?

If you would like help to quit smoking, please visit www.smokefreehampshire.com.

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

*
Sending