High Street 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): *

 /   / 

Contact Information:

Email Address:

Smoking Status:

What is your Smoking Status ? *


Terms & Conditions:

Please confirm by ticking the box below that you have read and accept our Terms & Conditions for using this online facility to send us your Smoking Status:


Why do you need my Email Address ?

We use this to send you a confirmation of your smoking status. We do not store your address on our system after the email has been sent. If you do not require a confirmation email simply leave this field blank.

Are my details secure ?

The Internet is not a secure medium. Please refer to our privacy page for further details. If after reading this you do not wish to use this form, please call or write to us requesting a paper copy of it.

Other Notes:

All fields marked with * are mandatory.