Update Your Smoking Status

If you wish to update us about your smoking status or you require help with stopping then please complete the questions below and submit online.

Please select the practice location most relevant to this Online Form submission:

1Update Your Smoking Status

Name

Address

Date of Birth

Home Telephone

Mobile Telephone

E.Mail Address

Smoking Status

Never smoked

Ex-smoker

Current smoker

If you are a current smoker, would you like to see our smoking cessation advisor for advice on stopping smoking and available drug therapy?

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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has 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
Riverside Surgery • Le Molay-Littry Way, Bovey Tracey, Devon, TQ13 9QP.

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.

Submit Form