NHS FORM - IPSWICH - Allen Carr's Easyway

Please note there is also a pre-seminar assessment form to complete once booking has finished, which is needed for the therapist.

How we will use your information.

We will only use your information to manage your appointments and provide services relevant to your health needs.
Anonymized data will be used for analysis of general health trends and for the purpose of evaluation, publication and research.
Your personal information and results will be kept secure and confidential. All data will be stored in accordance with General Data Protection Regulation.

Name(Required)

First Last

Do you smoke only, smoke & vape or vape only?(Required)

Do you smoke only or smoke & vape?(Required)

How soon after waking do you smoke your first cigarette?(Required)

Date of Birth(Required)

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Ethnicity(Required)

Religion(Required)

Marital status(Required)

Job category(Required)

Job category Thurrock(Required)

Job category – other(Required)

Are you on any benefits?(Required)

Please state the benefits you are on(Required)

GP Practice(Required)

Name of GP and address

Are you pregnant?(Required)

Sexual Orientation(Required)

Gender Identity(Required)

Is your gender the same as assigned at birth?(Required)

Do you pay for prescriptions?(Required)

NHS Registration form (Ipswich)