Smoking Review

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

Please Note – once you have submitted this information, any reply or acknowledgement from us will be sent to the email address you provide at top of the form. This response may include personal and sensitive information about you. We therefore strongly advise that you provide a personal email address that only you have access to. If you do not wish for us to communicate with you via email, please do not use this form and call us instead.

Smoking Review

Smoking Review

About You

Please use this date format: DD/MM/YYYY.
This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Smoking Review

Do not currently smoke section

Do currently smoke section

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

You can also visit Smokefreelife Berkshire for more information.

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