If you would like to register for our Smoking Cessation Service complete this formSmoking Cessation Please fill in this form and it will be emailed to your chosen pharmacy. The pharmacist will contact you as soon as they canName* Prefix MrMrsMissMsDrProf.Rev. First Last Date of Birth* DD MM YYYY Gender* Male Female OtherAre you pregnant? Yes NoEthnic GroupPlease SelectScottishIrishOther BritishPolishGypsy TravellerAsian IndianAsian PakistaniAsian BangladeshiAsian ChineseAsian OtherBlack AfricanBlack CaribbeanBlack OtherOther AfricanArabMixed (please specify):Other (please specify):Not DisclosedPlease specify ethnicityEmployment Status*Please SelectEmployed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workNot employed and not looking for workHomemaker/ Full time parent/ CarerRetiredStudentPrefer Not to AnswerPermanently Sick or DisabledAddress* Street Address Postcode* ZIP / Postal Code Local Davidsons Branch*Please SelectAberdeen - 340 Great Western RoadAberfeldy - 7 Bank StreetAboyne - Ballater RoadAlyth - 9 Airlie RoadArbroath - 59 Keptie StreetAuchterarder - 54-56 High StreetBallater - 10 Bridge StreetBanchory - 61-63 High StreetBlairgowrie - 21-24 WellmeadowBrechin - 41 High StreetBridge of Earn - Main StreetBridgend - 12-14 Main StreetBroughty Ferry - 120 Gray StreetClackmannan - 30 Main StreetComrie - Drummond StreetCoupar Angus - The CrossCrieff - 5 James SquareDrymen - 44 Main StreetDundee - 92 Clepington RoadDunkeld - 1 Bridge StreetElie - 42 High StreetForfar - 98 East High StreetFriockheim - 7 Gardyne StreetGarelochhead - Main StreetKillin - Main StreetLadybank - 30 Commercial RoadLetham - 26B Blairs RoadMcPherson Pharmacy - 120 Gray StreetMethven - 68 Main StreetMilnathort - 8-10 New RoadMuirhead - 117 Coupar Angus RoadNewburgh - 40 High StreetPanmurefield - Lawers Drive PanmurefieldPerth - 92-96 South StreetPitlochry (new) - 65 Atholl RoadPitlochry (old) - 112 Atholl RoadPortsoy - 1 Seafield StScone - 11-13 Angus RoadStanley - 31 Percy StreetStrathblane - 10 SouthView RoadThornton - 76 Main StreetPlease note that you may be contacted by a different pharmacist supporting your local branch from another locationYour GPPractice NameABBEY HEALTH CENTREABERCHIRDER MEDICAL PRACTICEABERFELDY AND KINLOCH RANNOCH MEDICAL PRACTICEABERFOYLE MEDICAL CENTREABERLOUR HEALTH CENTREABOYNE HEALTH CENTRE INCL. TARLANDACADEMY MEDICAL CENTREAIRLIE MEDICAL PRACTICEAIRTHREY PARK MEDICAL CENTREALBYN MEDICAL PRACTICEALFORD MEDICAL PRACTICEALLAN PARK MEDICAL PRACTICEALVA MEDICAL PRACTICEALYTH HEALTH CENTREANCRUM MEDICAL CENTREANCRUM MEDICAL CENTREANNAT BANK PRACTICEANSTRUTHER MEDICAL PRACTICEANTONINE MEDICAL PRACTICEARBROATH MEDICAL CENTREARDACH HEALTH CENTREARDBLAIR MEDICAL PRACTICEARK MEDICAL PRACTICEATHOLL MEDICAL CENTREAUCHENBLAE MEDICAL CENTREAUCHTERMUCHTY PRACTICEBALFRON HEALTH CENTREBALLATER CLINICBANCHORY GROUP PRACTICEBANFF AND GAMRIE MEDICAL PRACTICEBANK STREET MEDICAL GROUPBANNOCKBURN HEALTH CENTREBELLYEOMAN SURGERYBENNOCHY MEDICAL CENTREBLACKFRIARS MEDICAL PRACTICEBO'NESS ROAD MEDICAL PRACTICEBONNYBANK MEDICAL PRACTICEBRACKLINN PRACTICEBRAEMAR HEALTH CLINICBRAESVIEW MEDICAL GROUPBRECHIN MEDICAL PRACTICEBRIDGE OF ALLAN HEALTH CENTREBRIDGE OF EARN SURGERYBRIMMOND MEDICAL GROUPBROUGHTY FAMILY HEALTHCAREBUCHLYVIE SURGERYBUCKSBURN MEDICAL PRACTICEBYDAND MEDICAL GROUPCALSAYSEAT MEDICAL GROUPCAMELON MEDICAL PRACTICECAMPHILL MEDICAL PRACTICECARDEN MEDICAL CENTRECARNOUSTIE MEDICAL GROUPCARRON MEDICAL CENTRECARRONBANK MEDICAL PRACTICECASTLEGAIT SURGERYCENTRAL BUCHAN MEDICAL PRACTICECLACKMANNAN & KINCARDINE MEDICAL PRACTICECOLDSIDE MEDICAL PRACTICECOMRIE MEDICAL CENTRECOS LANE SURGERYCOUPAR ANGUS MEDICAL CENTRECOUPAR ANGUS MEDICAL CENTRECOWDENBEATH SURGERYCRAIGVINEAN SURGERYCRIMOND MEDICAL CENTRECROSSGATES MEDICAL PRACTICECRUDEN MEDICAL GROUPCULTS MEDICAL GROUPCUMINESTOWN MEDICAL PRACTICEDANESTONE MEDICAL PRACTICEDENBURN MEDICAL PRACTICEDENNY CROSS MEDICAL CENTREDEVERON MEDICAL PRACTICEDOLLAR HEALTH CENTREDOUNE HEALTH CENTREDOWNFIELD SURGERYDR ANDERSON & PARTNERSDR BORLAND & PARTNERS CCHCDR C M MACGLONEDR C WHITELAW & PARTNERSDR CHANDR HITCHCOCK'S PRACTICEDR K THOMPSONDR KYLE & PARTNERSDR MCLAREN & PARTNERSDR STEPHEN BROWNDR STIRLING & PARTNERSDRS BANDULARATNE, FLEMING, REES & WHEALDRS BEE, DUFFY, MCGOWAN, LINDSAY & STARBUCKDRS BLYTH, BURNETT, DOW, HARGREAVES & MACDONALDDRS BOGGON & HALFORDDRS DIXON, DUGGAN, EGERTON, FLYNN & MCCRICKARDDRS MCKEAN & LIMDRS MITCHELL, MORRIS & FORDYCEDRS PAGE, CLARK & MCDONALDDRS ROBSON, CARLIN & BROWNDRYMEN HEALTH CENTREDUNBLANE MEDICAL PRACTICEEAST PRACTICE, SPRINGFIELD MEDICAL CENTREEDENKILN SURGERYEDZELL HEALTH CENTREELGIN COMMUNITY SURGERYELLON GROUP PRACTICEELMBANK GROUP PRACTICEERSKINE PRACTICEFALLIN HEALTH CENTREFAMILY MEDICAL GROUPFEDDINCH MEDICAL PRACTICEFINLAYSON STREET PRACTICEFOCHABERS MEDICAL PRACTICEFORRES HEALTH CENTREFORTHVIEW PRACTICEFRIOCKHEIM HEALTH CENTREFYVIE OLDMELDRUM MEDICAL GROUPGARTHDEE MEDICAL GROUPGILBERT ROAD MEDICAL GROUPGLENLIVET MEDICAL PRACTICEGRAEME MEDICAL CENTREGREAT WESTERN MEDICAL PRACTICEGREEN PRACTICE, WHITEFRIARS SURGERYGROVE HEALTH CENTREHADDO MEDICAL GROUPHAMILTON MEDICAL GROUPHAWKHILL MEDICAL CENTREHEALTH CENTRE PRACTICE 2HILLBANK HEALTH CENTREHOLBURN MEDICAL GROUPHOSPITAL HILL SURGERYHOWE OF FIFE SURGERYINSCH MEDICAL PRACTICEINVERBERVIE MEDICAL GROUPINVERGOWRIE MEDICAL PRACTICEINVERKEITHING MEDICAL GROUPINVERURIE MEDICAL GROUPINZIEVAR MEDICAL PRACTICEKEITH MEDICAL GROUPKELTY MEDICAL PRACTICEKEMNAY MEDICAL GROUPKENNOWAY MEDICAL GROUPKERSIEBANK MEDICAL PRACTICEKILLEARN HEALTH CENTREKILLIN MEDICAL PRACTICEKINCORTH MEDICAL PRACTIICEKINGHORN MEDICAL PRACTICEKINGLASS MEDICAL PRACTICEKINGS PRACTICEKINLOSS MEDICAL CENTRE (ARMY)KIPPEN SURGERYKIRRIEMUIR MEDICAL PRACTICELAURENCEKIRK MEDICAL GROUPLENY PRACTICELESLIE MEDICAL PRACTICELINBURN ROAD HEALTH CENTRELINKS MEDICAL PRACTICELINKWOOD MEDICALLOCHEE HEALTH CENTRELOCHGELLY MEDICAL GROUPLOUR ROAD GROUP PRACTICEMACDUFF MEDICAL PRACTICEMARKINCH MEDICAL PRACTICEMARYFIELD MEDICAL CENTREMARYHILL GROUP PRACTICE INCL. ROTHESMARYWELL HEALTHCARE CENTREMAUVE PRACTICE, DRUMHAR HEALTH CENTREMEEKS ROAD SURGERYMETHILHAVEN SURGERYMILL PRACTICEMILLHILL SURGERYMINTLAW GROUP PRACTICEMONIFIETH HEALTH CENTREMORAY COAST MEDICAL PRACTICEMUIREDGE SURGERYMUIRHEAD MEDICAL CENTRENETHERGATE MEDICAL CENTRENETHERTOWN SURGERYNEW PARK MEDICAL PRACTICENEWBURGH SURGERYNICOL STREET SURGERYNORTH GLEN MEDICAL PRACTICENORTHFIELD/MASTRICK MEDICAL PRACTICEOCHILVIEW PRACTICEOLD ABERDEEN MEDICAL PRACTICEOLDMACHAR MEDICAL PRACTICEORCHARD HOUSE HEALTH CENTREORWELL PRACTICEPARK AVENUE MEDICAL CENTREPARK AVENUE MEDICAL CENTREPARK ROAD PRACTICEPARK TERRACE MEDICAL PRACTICEPARKVIEW PRACTICEPATH HOUSE MEDICAL PRACTICEPETERCULTER MEDICAL PRACTICEPETERHEAD HEALTH CENTREPITCAIRN PRACTICE LEUCHARS & BALMULLOPOLMONT PARK MEDICAL PRACTICEPORTLETHEN MEDICAL CENTREPORTSOY MEDICAL PRACTICEPRIMROSE LANE MEDICAL CENTREPRINCES STREET SURGERYRAVENSWOOD SURGERYRED PRACTICE, WHITEFRIARS SURGERYRHYNIE SURGERYRINNES MEDICAL GROUPROSEMOUNT MEDICAL GROUPROTHES MEDICAL PRACTICERUBISLAW PLACE MEDICAL GROUPRYEHILL MEDICAL PRACTICESALTOUN SURGERYSCOTSTOWN MEDICAL GROUPSEAFIELD & CULLEN MEDICAL GROUPSKENE MEDICAL GROUPSLAMANNAN MEDICAL PRACTICEST MARGARET'S HEALTH CENTREST NINIANS MEDICAL PRACTICEST SERF'S PRACTICESTANLEY MEDICAL CENTRESTATION HEALTH CENTRE RAF LOSSIEMOUTHSTENHOUSE PRACTICESTOBSWELL MEDICAL CENTRESTONEHAVEN MEDICAL GROUPSTRATHCAIRN MEDICAL PRACTICESTRATHCARRON HOSPICESTRATHDON MEDICAL CENTRESTRATHMORE SURGERYTAY COURT SURGERYTAYBANK MEDICAL CENTRETAYVIEW MEDICAL PRACTICETERRA NOVA MEDICAL PRACTICE LLPTHE BLUE PRACTICETHE CANNONS PRACTICETHE CARSE MEDICAL PRACTICETHE GLENWOOD PRACTICETHE LOMOND PRACTICETHE MEDICAL CENTRETHE RED PRACTICETHE RICHMOND PRACTICETHE TAYMOUNT SURGERYTHE WALLACE MEDICAL PRACTICETILLICOULTRY MEDICAL PRACTICETORPHINS MEDICAL PRACTICETORRY MEDICAL PRACTICETOWNHEAD PRACTICETRYST MEDICAL CENTRETURRIFF MEDICAL PRACTICEVALLEYFIELD MEDICAL PRACTICEVARIS MEDICAL PRACTICEVICTORIA PRACTICEVICTORIA STREET MEDICAL GROUPVIEWFIELD MEDICAL PRACTICEVIEWPOINT MEDICAL PRACTICEWALLACE MEDICAL CENTREWALLSGREEN MEDICAL PRACTICEWEST PRACTICE, SPRINGFIELD MEDICAL CENTREWESTBURN MEDICAL GROUPWESTBURN MEDICAL PRACTICEWESTGATE MEDICAL PRACTICEWHINHILL MEDICAL PRACTICEWHITFIELD SURGERYWOODSIDE MEDICAL GROUPYELLOW PRACTICE, DRUMHAR HEALTH CENTREPhone*Email* Preferred Contact Method*TelephoneEmailTobacco use and quit attemptsOn average, how many cigarettes do you usually smoke per day?* 10 or less 11-20 21-30 More than 30 UnknownHow soon after waking up when do you usually smoke your first cigarette?* Within 5 minutes 6-30 minutes 31-60 minutes After one hour UnknownHow many times have you tried to quit smoking in the past year?* No quit attempts Once 2 or 3 times 4 or more times UnknownAny other information you wish to provideConsent to contact your GP practice* Yes NoPlease tick here if you DO NOT wish your GP practice to be contacted with the outcome.CAPTCHAEmailThis field is for validation purposes and should be left unchanged. 4714