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Smoke Free Photograph

Please complete the form below with as much detail as possible. Everything you tell us will be treated in the strictest confidence.

Once we receive your details a SPECIALIST ADVISOR will contact you by telephone.

If you have any queries or problems in completing the form please do not hesitate to call us on 0800 0854 113

Thank you.

Please note that for confidentiality when you send this form your email address will not be shown to our adviser. If you would like us to respond by email please enter your email address into the box below. (Your details will not be shared with any other person, company or agency)

(Required information)

Name:
Email:
Phone Number:
Best time for us to contact you:
Can a message be left?:
Address:
GP Name:
GP Practice:
Number of attempts to quit:
Number of cigarettes/amount of tobacco used per day:
Any health problems related to your smoking:
[e.g. Cough, Chest Infeection]
Any other details: