Fishponds Primary Care Centre, Beechwood Road
Fishponds, Bristol BS16 3TD
0117 908 2360
   
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Would you like to give up smoking?

Please answer the following questions and click on the button at the bottom of the page to submit by secure email.

1.   On a scale of 1-10 (where 10 is the most) please mark how much you would like to give up smoking:

1     2     3     4     5     6     7     8     9     10

2. There are many reasons you might want to quit smoking; some are listed below.  Please tick those that apply to you and add any others you may have:

 
 
 
Other, please explain:  

3. If you have tried giving up before please tell us how successful you were:

Someone from the Smoking Cessation team will contact you as soon as possible, but please be patient, as it may be a couple of weeks before we do.

Please provide us with your contact details below:

Full name*:  
Date of birth*:
Telephone*:  
Email address:
Date*:  
   
   
 

* Compulsory field 

Security Issues
The information you submit will be treated in the strictest confidence. However, we cannot guarantee the security of global internet/email systems. This means that it is possible (although unlikely) that your request may be read by someone other than us. If you are concerned about this possible loss of privacy please contact the practice personally instead of using this form.

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