Smoking Cessation Consultation e-form

Smoking Cessation Consultation e-form
NOT eligible for this service: 1. People presenting for ongoing or repeat NRT is NOT to be claimed as a MidCPG Consultation 2. Vapers are NOT eligible for this cessation service
Patient Information
NHI
Date of Birth

DayMonthYear
Free type or use calendar date picker
Ethnicity
Town
Informed consent | Healthify
Patient Consent
Consultation Data
Smoking Status
Health Conditions

Other
Completed Actions
Pharmacist Declaration
Pharmacist Full Name

First NameLast Name
Pharmacy Dispensary Email
Pharmacy Name (choose from list)
Pharmacist Declaration:
Signature
Consultation Date

DayMonthYear
Free type or use calendar date picker
Patient Full Name (REMOVE via PETE 15/12/2025)

First NameLast Name
Should be Empty: