The Stop Smoking Agreement
I have seriously thought about trying to stop smoking and would like to enrol in the Stop-Smoking programme.
I understand that it will last a year and consist of the following:
1. An initial 20-minute appointment with one of the practice nurses, during which issues relating to cigarette addiction and behaviour will be discussed based around my completed ‘Giving Up for Life’ booklet. The types of aids available to help me will also be covered and, if we feel it appropriate, one will be prescribed for me.
2. Follow-up appointments with Tricia or Ellen, which will usually be 10 minutes long, will be important in re-emphasising successes and dealing with difficulties.
3. Later follow-up appointments, which will either be 10 minutes direct contact or by telephone, will build on the achievements so far.
I also understand that entry into the programme is generally only once per year. Leaving the programme will occur under the following circumstances:
a. I do not wish to continue and I inform the nurse of this.
b. I cancel an appointment without giving a minimum of 24 hours notice, unless under exceptional circumstances.
c. I miss an appointment without giving good reason or due notice. In this case it will not be possible to re-enter the programme at St Wulfstan Surgery in the future.
The Stop Smoking Agreement: I have seriously thought about trying to stop smoking and would like to enrol in the Stop-Smoking programme. I understand that it will last a year and I agree to the following:
Please contact the surgery in a few days to arrange a smoking cessation appointment with one of the nurses.
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.