Smoking Review Wycliffe

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

Last Updated: 24/04/2020

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Smoking Review

    Do you currently smoke?
    If 'Yes' How many do you smoke in a day? (optional)
    If 'No' Have you smoked in the past? (optional)
    If you are a smoker and you would like information or help with stopping smoking (optional)
    THIS FORM COLLECTS PERSONAL AND MEDICAL DETAILS AS ABOVE. PLEASE CONFIRM YOU ARE REGISTERED WITH WYCLIFFE SURGERY AND THAT YOU CONSENT TO THE PRACTICE TEAM UPDATING YOUR NHS MEDICAL RECORDS. IF YOU WOULD LIKE TO KNOW HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA, PLEASE READ OUR PRIVACY POLICY.
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