Smoking Status

Keep your records up to date and inform the practice of your current smoking status by completing the Smoking Status Update Form!

1Smoking Status

Please select from drop down list
Please select from drop down list
Please select one of the above status'
Please select date
Please select from drop down list
Please select from drop down list

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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27 Parkfield Road , Coleshill, Warwickshire, B46 3LD
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