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Menu
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About Us
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Have your Say
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Allied Professionals that work in our practice
Attached Health Care Professionals
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At the Practice
Data
Patient Record
Patient Rights
Website
Teenage Friendly
Training Practice
Clinics & Services
Appointments, Tests & Referrals
Appointments
Referral for Further Care
See a Doctor or Healthcare Professional
Self Referral Services
Tests & Investigations
Clinics
Antenatal Care
Child Health Checks
Our Clinics
Long Term Conditions
Online Services
Practice Services
Repeat Prescriptions
Travel Clinic
Register with us as a New Patient
Step 1: New Patient Registration Form
Step 2: Upload scans of photo identity and proof of address
Forms
Keep us up-to-date
Electronic Reviews
New Patient Registration
Help & Support
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McGlone Practice
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Smoking Review Form
Smoking Review Form
Smoking Review
First Name
*
Last Name
*
Email
*
Enter Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Your Smoking Status
Do you currently smoke?
*
Yes
No
How many cigarettes do you smoke each day?
1 to 9
10 to 19
20 to 39
40 or more
Would you like to give up smoking?
Yes
No
Did you smoke in the past?
*
Yes
No
How many cigarettes did you smoke each day when you were a smoker?
1 to 9
10 to 19
20 to 39
40 or more
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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Have your Say
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Allied Professionals that work in our practice
Attached Health Care Professionals
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Website
Teenage Friendly
Training Practice
Clinics & Services
Appointments, Tests & Referrals
Appointments
Referral for Further Care
See a Doctor or Healthcare Professional
Self Referral Services
Tests & Investigations
Clinics
Antenatal Care
Child Health Checks
Our Clinics
Long Term Conditions
Online Services
Practice Services
Repeat Prescriptions
Travel Clinic
Register with us as a New Patient
Step 1: New Patient Registration Form
Step 2: Upload scans of photo identity and proof of address
Forms
Keep us up-to-date
Electronic Reviews
New Patient Registration
Help & Support
News