Crown Surgery

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Smoking Status


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

General Information:

Patient Identification:

Patient Number: (if known)

Firstname (1st 3 Chars): *

Surname (1st 3 Chars): *

Date of Birth (dd/mm/yyyy): *

 /   / 

Contact Information:

Email Address:

Smoking Status:

What is your Smoking Status ? *


Terms & Conditions:

By clicking on the check box you are confirming that, with regard to this facility, you agree with the Terms and Conditions for its use, you consent to the practice collecting and storing your data from it and you give your consent for the practice to contact you (by email, text message and/or telephone) about it.


Where do I find my
Patient Number ?

If you do not know your Patient Number just leave this field blank as it is not mandatory, it just helps us to identify you. However it is the 'Patient ID / Number' found on your prescription slips if you have them.

Why do you need my Email Address ?

We use this to send you a confirmation of your smoking status. We do not store your address on our system after the email has been sent. If you do not require a confirmation email simply leave this field blank.

Other Notes:

All fields marked with * are mandatory.