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:

Name

Address

Date of BirthPlease enter Date of Birth as DD/MM/YYYY

Home Telephone

Mobile Telephone

E.Mail Address

Smoking Status

If you are a current smoker and would like to see our smoking cessation advisor for help on stopping smoking please book an appointment at the surgery.

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 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.

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