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Beauchamp House Surgery

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Submit a Request
Appointments
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Latest Practice News
Travel Clinics
Join the Practice
Services We Offer
Health Information
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Contact Us
Chelmsford City Health PCN Limited
Patient Participation Group

Home
Language
Self Help and Local Support Services
Online Services
Opening Times and Out of Hours
Carers Support
About Us
Our Staff
Compliments and Complaints
Practice Policies
Chelmsford City Health PCN Limited

Beauchamp House Surgery is now offering free NHS Health Checks. We'll send you a text with an appointment invite link so you can book your preferred time.

What is an NHS Health Check? An NHS Health Check is a free check-up delivered by health professionals for adults aged 40 to 74 to help lower the risk of developing serious health conditions. They are

Find out more

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Smoking Review Form

Smoking Review Form

Smoking Review Form

If you have been advised by the surgery to a submit smoking review please use this form.

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Smoking Review

Do you currently smoke? *

Yes No

If 'Yes' How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

If 'No' Have you smoked in the past?

Yes No

IF 'YES' HOW MANY CIGARETTES DID YOU SMOKE IN A DAY?

1 to 9

10 to 19

20 to 39

40 or more

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 16 September 2024
Page created: 13 March 2023

Further Information

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