Application for free vape and kits (max 5 mins)

First Name:

Second Name

Phone Number:

DOB:

Address:

Post Code:

Best Time To Call: Best Time To Call: Morning Afternoon Weekends

GP Practice:

Are You Exempt From Prescription Charges: Are You Exempt From Prescription Charges: Yes No

If Yes, Please Provide A Reason:

Occupation Status:

How Were You Made Aware Of This Service:

Reasons For Quitting : Tick All That Apply Reasons For Quitting : Tick All That Apply Worried About Health Benefits To Family Can't Afford To Continue GP Instruction

How Soon After You Wake Up Do You Have Your First Cigarette: How Soon After You Wake Up Do You Have Your First Cigarette: Within 5 Mins 6 Mins - 30 Mins 31 Mins - 1 Hour After 1 Hour

How Many Cigarettes Do You Smoke A Day? How Many Cigarettes Do You Smoke A Day? Less Than 10 11 - 20 21 - 30 30 +

Do You Smoke More In The Morning Or Steadily Throughout The Day?

If You Were Sick In Bed, Would You Still Have A Cigarette?

Quit Date: