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Mountsandel Medical Centre

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Appointments
Prescriptions
Join the Practice
Opening Hours
Services
Health Information
Contact Us

Home
About Us
Our Staff

Mountsandel Medical Centre

We will be closed a half day on Wednesday 16th October at 1.00pm for staff training.

Find out more

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Smoking Review Form

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

Last Updated: 30/06/2024

Your Details

Name *

Date of Birth *

Phone Number *

Email Address *

Smoking Review

Do you currently smoke? *

Yes No

Do you vape? *

Yes No

If 'Yes' How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

If 'No' Have you smoked in the past?

Yes No

IF 'YES' HOW MANY CIGARETTES DID YOU SMOKE IN A DAY?

1 to 9

10 to 19

20 to 39

40 or more

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

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