Referral : Welcome

Please fix the following issues before continuing:

Consent Statement : "Any personal information you provide will be held in accordance with the General Data Protection Regulation (EU) 2016/679 and used for processing your attendance on the programme. We will share your data with Everybody Health and Leisure, Cheshire East Council commissioner of the service and your Healthcare Professional. Are you happy to proceed?"

Before submitting this form, please check if you or a person you are referring is eligible for Swap to Stop scheme. Swap to Stop scheme is designed for current tobacco smokers aged 18+ who are Cheshire East residents. We cannot accept referrals for anyone who has already stopped smoking and/ or are interested in stopping vaping.

Consent to record information *

Yes

Title *

Firstname *

Lastname *

DOB *

Referral Type *

Address *

Letter allowed? *

Yes

Postcode *

Tel

Mobile *

SMS allowed? *

Yes

Email *

Email allowed *

Yes

How many cigarettes do you smoke? *

less than 10

11-20

21-30

more than 30

Please choose a starter kit: *

Tornado GTL with 5 x Switz E-liquid

Skope Air with 5 x Switz E-liquid

Please choose nicotine level *

10mg = 1%

16mg = 1.6%

6mg = 0.6%

Please choose your preferred flavour *

Referral Form