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Stop Smoking Consultation

1

(must match billing name - as per I.D)

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9

(A quit date is the planned day to stop smoking)

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Epilepsy Diabetes Mental health conditions such as bipolar disorder, an eating disorder, Cardiovascular (heart) problems Kidney or liver problems, Alcohol abuse, Brain tumour, Seizures Benzodiazepine withdrawal

Epilepsy Diabetes Mental health conditions such as bipolar disorder, an eating disorder, Cardiovascular (heart) problems Kidney or liver problems, Alcohol abuse, Brain tumour, Seizures Benzodiazepine withdrawal

12

For example: Sertraline, Fluoxetine, Escitalopram, Venlafaxine or Citalopram

For example: Sertraline, Fluoxetine, Escitalopram, Venlafaxine or Citalopram

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Enter GP details Manually or search via GP postcode/name.

I agree that the information I have provided is correct and I give consent to Dr Weightmans Pharmacy to verify this information with my SCR (Summary Care Records) if required.
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