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Wycliffe Surgery NHS Devon ICB

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Smoking Review

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Smoking Review

If you have been advised by the surgery to submit a smoking review, please use the form below.

Step 1 of 4

25%

Name

First Last

Phone Optional

Date of Birth

Day

Month

Year

Email Optional

Do you currently smoke?

Yes

If yes, how many do you smoke in a day?

1 to 9 Optional

10 to 19 Optional

20 to 39 Optional

40 or more Optional

If no, have you smoked in the past?

Yes Optional

No Optional

If you are a smoker and you would like information or help with stopping smoking:

Consider calling the surgery to book an appointment with one of our Smoking Cessation Nurses Optional

Consider visiting the NHS smoke free website Optional

Keep these options in mind for future if you are not quite ready to quit. Optional

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.

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

30208

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