Saville Medical Practice

Are You A Smoker?

Thank you for taking the time to tell us about your Smoking Status (whether you are a smoker, ex-smoker or have never smoked).

Your details

First Name

Second Name

Post Code

Date of Birth

Phone Number

Email Address

Smoking Status

Smoker

Ex-Smoker

Never Smoked

Please complete this form and hand it in to reception.

The information you supply us will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Are You A Smoker?

Thank you for taking the time to tell us about your Smoking Status (whether you are a smoker, ex-smoker or have never smoked).


Your details

Phone number


Smoking Status

Please read this

If you care for more than one person please complete another form.

The information you supply us will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should print this page and complete the form in writing before returning it to us by post or by handing it in to reception.