Gnosall Surgery

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Smoking Status


Thank you for taking the time to tell us about your Smoking Status (whether you are a smoker, ex-smoker or have never smoked). The process will only take a minute.

General Information:

Patient Identification:

Firstname (1st 3 Chars): *

Surname (1st 3 Chars): *

Date of Birth (dd/mm/yyyy): *

 /   / 

Smoking Status:

What is your Smoking Status ? *


Terms & Conditions:

By clicking on the check box you are confirming that, with regard to this facility, you agree with the Terms and Conditions for its use, you consent to the practice collecting and storing your data from it and you give your consent for the practice to contact you (by email, text message and/or telephone) about it.


Other Notes:

All fields marked with * are mandatory.