Quit Online Registration

Quit Online Registration (step 1 of 4)

We just need to know a little bit about you before you are on the road to quitting smoking (Click here to return to the Login page):


Email		Required (You will be sent an email to activate your account)

Password		Required

Confirm password		Required

About You

Title

Required

First name

Required

Last name

Required

Address

Required

Post code

Required

Home telephone number

Required

Mobile telephone number

Date of birth

Required
(your date of birth is required, for your FREE NRT)

Male

Female

GP name

Required

GP practice

Required

Where did you hear about the service?

Required

Are you pregnant?

Yes No

Have you been diagnosed as having COPD?

Yes No

Do you pay for prescriptions?

Yes No

Would you be willing to participate in publicity?

Yes No

Do you have any other medical conditions?

Ethnic origin

Required

Occupation

Required

How much on average do you spend on cigarettes a day?

Required

Why do you want to give up?

Required

As part of Quit Online you get FREE Nicotine Replacement Therapy (NRT) products, like patches or gum throughout your programme. Someone from the Stop Smoking Service will ring you within 3 days. This is to ensure you get the product most suitable for you. Once you have received this phone call- you will get an email with an NRT voucher code which you can take to your chosen chemist to collect your weekly NRT.

Which chemists would you like to collect your NRT from each week?
(you can only select one and your voucher code will only be valid at this chemists)

Choose your Chemist

Required

Your details will not be passed onto any 3^rd party and they will only be used for the purpose given.