Stop Smoking Service Referral Form

If you submitted a referral via our online form between 22 June 2023 and 30 June 2023, there has been an external technical error which means we did not receive your submission. 

You would have received a confirmation email that we received your referral, however, we did not.

Our sincere apologies to those who took the time and effort to complete this form and appreciate how frustrating this is.

If this applies to you, we kindly ask that you please resubmit your form (we've triple-checked the form is working now!)

To be contacted about the Stop Smoking service, please complete the online form below.  

Fields marked with an asterisk (*) are compulsory fields.

Alternatively, you can phone: 0800 NO SMOKE (0800 667 665) or email: [email protected].

Note: Your information is safe with us. The personal information you give to us via an online form is not stored on our website, or accessible from this site. See our Privacy Disclaimer for more information.