Smoking Cessation e-form

Smoking Cessation e-form
NHI*
Patient Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Free type or use calendar date picker
Ethnicity*
Town*
Informed consent | Healthify
Patient Consent*

I understand and agree to participate in a consultation with my Pharmacist. I consent to my pharmacist accessing relevant medical and hospital records to support my health care. I agree that anonymised data may be used to improve the service.
Smoking Status*

Current Smoker wishing to quitStopped - but strugglingStopped - but started againVaper (not eligible for this consultation)
Health Conditions*

AsthmaDiabetesCOPDCardiovascular diseasePregnant/breast feedingOther
Completed Actions*

Educated on smoking cessation using ABC techniqueProvided lifestyle adviceDispensed NRT and provided NRT educationReferred to GP for alternative medicine therapy (eg. Champix)Referred patient to a quit coach or quit programme
Pharmacy Name (choose from list)*
Pharmacist Full Name*

First NameLast Name
Pharmacy Email*
MUST be completed to receive copy of PDF for pharmacy records
Pharmacist Declaration:*

I agree that I have explained the consent process to the patient and have conducted a comprehensive consultation utilising the MidCPG Smoking Cessation Consultation Checklist.
Signature*

Clear
Date of Consultation *

DayMonthYear
Free type or use calendar date picker
DOCUMENT VERSION CONTROL: Smoking Cessation Consultation Form V1.0

FULL NAME field Hidden 15/12/2025 as per Pete Chandler
Should be Empty: