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Health Promotion Service Cornwall and Isles of Scilly

Stop Smoking Service

Self Referral Form

Click here for the Easy Read version of this form

Please complete all mandatory fields marked *

Personal details

First name *
Last name *
Gender *

Address lines 1 *
Address lines 2 
Address lines 3 
Address town *
Postcode *
Date of birth *
Home telephone 
Work telephone 
Email address 
GP Surgery *
What support do you require *
Other type of support 
How did you hear about this? *
Have you had a health check with your GP? *

What is an NHS Health Check?

The NHS Health Check is your chance to get your free midlife MOT. For adults in England aged 40-74 without a pre-existing condition, it checks your circulatory and vascular health and what your risk of getting a disabling vascular disease is.

Consent to contact and data retention

I consent to contact *

By phone 
By email 
By letter 
I consent to GP contact *

As a health record this form will be retained in line with the NHS Retention and Destruction Schedule. By submitting this form you consent to us holding this information. *

Pregnancy Details

Are you pregnant? * 

Midwife name 
Midwife base 
Midwife phone 
Midwife email 
Due date 
Hospital number 

Disability Details

Do you have a disability? *

Type of disability 
Other disability 

Additional information