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.
Please include postcode
Please use this date format: DD/MM/YYYY.
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.