When you have booked an appointment fill in this page, sign, date, and and print it out and send to: Centre One Practice 10 Burghley Road London NW5 1UE
Full name
Address
Telephone (home)
Telephone (work)
Telephone (mobile)
Age
Sex
M
F
Marrital status
Are you currently under the care of a doctor?
Y
N
Did your doctor recommend you stop smoking?
Y
N
Doctors's name and surgery
It is standard procedure for us to notify your Doctor about this smoking cessation programme. Is that alright?
Y
N
How many cigarettes do you smoke a day?
When did you start smoking and why?
What methods (if any) have you used to try to stop smoking before?
What is your profession?
Who referred you, or how did you hear about me?
Signed
Date
