Smoking Status and Cessation

Please complete the form below to keep us up to date with your smoking status.

If you would like help to stop smoking, please ask one of the doctors, nurses or a member of the reception staff.

Alternatively contact the Stop Smoking Service patient Quit line number on 0800 0525 855.

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

Find my NHS Number (opens in new window)

Your Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

Smoking Status

Do you smoke?

Yes

If you used to smoke when did you stop?

Do you use an e-cigarette?

Yes

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Grafton Road Surgery • 11 Grafton Road, Shirley, Solihull, West Midlands, B90 1NG.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.