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Please use the form below to book a one-to-one session with one of our stop smoking advisors, contact us for more information or to leave us some feedback. We look forward to hearing from you!

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  • This is a secure form. The details you provide will be sent to our secure nhs.net email address
Date of birth
Gender
Preferred time(s) to call to arrange the next step
May we leave a message?
Preferred time(s) for an appointment
Preferred type(s) of consultation call
Does the client need to stop smoking in preparation for an operation?
Has the client been diagnosed with a mental health condition?
Is the client pregnant?
Due date
Does the client suffer from diabetes?
Has the client been diagnosed with any of the following long term health conditions?
Preferred clinic location (if known)
Has the client consented to receiving information from the practice/pharmacy on stopping smoking and/or the services available?
Name of referring practice/pharmacy/other
Name of GP/health professional/pharmacist

    CNWL would encourage you to provide your consent in order that we can process data and information about you. We will share this data where necessary with other health professionals such as your GP or specialist services. The information we collect and process will be used to help us meet the contractual obligations as set down by the local health service commissioners in accordance with the service we are providing. You can request to view, amend or delete your data at any time by contacting us at (www.cnwl.nhs.uk/about/contact).

  • Solutions4health would encourage you to provide your consent in order that we can process data and information about you and your child. As the child is under 16 years of age, we require your consent as a parent/ guardian/ nominated adult to give consent for us (Solutions4Health) to process their data. We will share this data where necessary with other health professionals such as your GP or specialist services. The information we collect and process will be used to help us meet the contractual obligations as set down by the local health service commissioners in accordance with the service we are providing. You can request to view, amend or delete your data at any time by contacting us at (www.solutions4health.co.uk/contact-us).