Staff Smokefree Self Referral Form

All information provided will remain confidential and will be used by Blackpool Teaching Hospitals NHS Foundation Trust and anonymously by Public Health Departments for evaluation purposes only.

Please tick the box if you agree for your details to be kept on a secure database designed and administered by AN Computing.

Name:

Address:

Postcode:

GP Practice:

Date of Birth:

Contact number:

Email address:

Which of the Trust's sites do you work at?

How did you find out about our stop smoking services?

I am a current smoker

I consent to contact

I consent to data recording

By clicking 'Submit', I confirm that I have read and understand, and agree to the contents of this form.

Please leave this field empty.