Start your smoke free journey

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Your Details - Stop smoking

This form is for tobacco smokers who wish to refer themselves for advice and support.

To access this service you will need to live/work/study in Barnet.

First name (Required)

Last name (Required)

Date of birth (Required)

Your telephone number (Required)

Your email address (Required)

Your Postcode This service is for those who live, work or study in Barnet (Required)

Postcode

GP Surgery name (Required)

I confirm I am the patient or have the patient’s authority to make this request (Required)

Yes

I confim I am currently a tobacco smoker (Required)

Yes

Are you currently pregnant? (Required)