Smoking Status Update

Collects smoking status of a patient

Last Updated: 13/01/2020

Name and contact details

First Name *

Last Name *

Date of Birth *

First Line of your home address *

Mobile phone number

Home telephone number

Email address

Smoking Status

Collecting current patient status

We would like to update your medical record. Please choose from one of the options below *

Consent

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.

I consent to the practice collecting and storing my data from this form. *

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Smoking Status Update

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