Smoking Status

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

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Your Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

Smoking Status

Do you smoke?

Yes

If you used to smoke when did you stop?

Do you use an e-cigarette?

Yes

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Beechdale Surgery • Edison Road, Walsall, WS2 7EZ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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