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Healthy Cornwall

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 
Mobile 
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 *

The information you provide to Healthy Cornwall will be stored securely in accordance with Section 7 of the Data Protection Act 1998 and only accessed and processed by relevant staff. Your information will be used for the purpose of providing a service to you; it would be shared only if there was a legal reason to do so i.e. safeguarding concerns. The information may also be used, once anonymised, for reporting purposes. You have the right to restrict and/or withdraw consent at any time for us to store and process your information. For more information, please refer to our Privacy Notice which can be found on the Healthy Cornwall website www.healthycornwall.org.uk which complies with General Data Protection Regulations 2018.

I confirm that I have read the above statement and consent to it. *

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

Notes