Name*

Title First Name Last Name

Date of Birth*

Gender*

Are you pregnant?

Ethnic Group*

Please specify ethnicity

Employment Status*

Address*

Street Address Address Line 2 City Postcode

Preferred Contact Method*

Phone*

Email*

Local Davidsons Branch*

Please note that you may be contacted by a different pharmacist supporting your local branch from another location

Your GP*

Tobacco use and quit attempts

On average, how many cigarettes do you usually smoke per day?*

How soon after waking up when do you usually smoke your first cigarette?*

How many times have you tried to quit smoking in the past year?*

Any other information you wish to provide

Consent to contact your GP practice*

Please tick here if you DO NOT wish your GP practice to be contacted with the outcome.

Phone

This field is for validation purposes and should be left unchanged.

Form – Smoking Cessation