Smoking Cessation Self-Referral

To refer yourself to our Stop Smoking Service please complete and submit this form.

Smoking Cessation Self-Referral Form

Smoking Cessation Self-Referral Form

Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY.
What is the best time of day to call?
may we leave a message?
If there is no phone may we send a letter?
Please include postcode
Do you require to quit as preparation to an operation?
Have you been diagnosed with a mental health condition?
Are you pregnant?
Please use this date format: DD/MM/YYYY.
Do you suffer from diabetes?
Have you been diagnosed with any of the following?
Solutions4health would encourage you to provide your consent in order that we can process data and information about you. We will share this data where necessary with other health professionals such as your GP or specialist services. The information we collect and process will be used to help us meet the contractual obligations as set down by the local health service commissioners in accordance with the service we are providing. You can request to view, amend or delete your data at any time by contacting us at www.solutions4health.co.uk/contact.
Consent *