Stop Smoking Support: Self-Referral
Use this form to request stop smoking support and an in-store appointment. We will initially contact you via email to confirm eligibility, answer any questions, and help you get started. If you would like to complete the optional pre-screen online, use the secure link provided after you submit.
📝 Self-referral form
This form collects basic contact and eligibility information only. Please do not include medical or sensitive personal information here.
⚠️ Important
This page is for self-referrals and appointment requests only. Please do not submit urgent health concerns through this form. If you need urgent medical help, contact NHS 111 (or 999 in an emergency).
❓ FAQs
What happens after I submit?
We will contact you via email first to confirm eligibility and arrange your in-store appointment. You can also complete the optional secure pre-screen in advance using the link provided.
Do I have to complete the pre-screen?
No. It is optional. Completing it helps us prepare, but we can do it with you in-store if you prefer.
Why don’t you collect all details on this page?
Some information should only be collected through a secure system. This keeps your information safer and keeps the process compliant.