Smoking Cessation Questionnaire

Please complete the online form below. (Compulsory fields are marked *)

Your Personal Details

First Name *

Last Name *

Date of Birth *

CHI Number

Address *

Postcode *

Home Phone No. *

Mobile Phone No.

Email *

GP Name *

Pregnant

Tobacco use & quit attempts

Preferred branch *

Confirmation

By participating in the smoking cessation service the client has agreed to be contacted by NHS Scotland representatives in order to follow up their progress and smoking status and has agreed to provide a telephone number to facilitate follow up *

Please confirm you are not a robot

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