Smoking Review

If you have been advised by the surgery to submit a smoking review on a regular basis please use this form.

Smoking Review

If you currently do not have a fixed address, please enter in the address field no fixed abode.

Smoking Review

Do you currently smoke? *

Do not currently smoke section

Have you smoked in the past? *
How many cigarettes did you smoke in a day? *

Do currently smoke section

How many cigarettes do you smoke in a day? *
Do you use e-cigarettes? *

If you wish to give up smoking, please call the free self-referral line on 08000 852 299. They are able to offer help and support in a variety of ways and they also hold clinics at Swadlincote Health Centre