Weeping Cross, Beaconside & JAD Surgeries

Smoking Status

Introduction:

Thank you for taking the time to tell us about your Smoking Status (whether you are a smoker, ex-smoker or have never smoked). The process will only take a minute.

General Information:

Patient Identification:
Firstname (1st 3 Chars): *
Surname (1st 3 Chars): *
Date of Birth (dd/mm/yyyy): *	/ /

Contact Information:
Email Address:

Smoking Status:
What is your Smoking Status ? *	Smoker Ex-Smoker Never-Smoked

Terms & Conditions:
Please confirm by ticking the box below that you have read and accept our Terms & Conditions for using this online facility to send us your Smoking Status:

Instructions

Why do you need my Email Address ?

We use this to send you a confirmation of your smoking status. We do not store your address on our system after the email has been sent. If you do not require a confirmation email simply leave this field blank.

Are my details secure ?

The Internet is not a secure medium. Please refer to our privacy page for further details. If after reading this you do not wish to use this form, please call or write to us requesting a paper copy of it.

Other Notes:

All fields marked with * are mandatory.