Smoking Review Form

First Name *

Last Name *

Email *

Date of Birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Your Smoking Status

Do you currently smoke? *YesNo

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *I consent to the practice collecting and storing my data from this form.