When You’re Ready To Quit, We’re Ready To Help Complete the form below and a specialist stop smoking advisor will call you back. Alternatively give us a call or send us an email. Self Referral First Name * Last Name * Date of Birth * Gender * Please Select Male Female Prefer not to say Other Gender Phone * Email Address * Address Address Address City City County County Postcode Postcode Postcode of employment Do you live, work or have a GP registered in (Oldbury, Rowley, Smethwick, Tipton, Wednesbury, West Bromwich) Sandwell? * Yes No GP Surgery Please select one Horseley Heath Surgery Tandon Medical Centre Village Medical Centre Smethwick Medical Centre Hollybush Medical Centre Warley Medical Centre Your Health Partnership, Regis Medical Centre Your Health Partnership, Rowley Village Surgery Your Health Partnership, Oakham Surgery Your Health Partnership, Carters Green Medical Centre Your Health Partnership, Whiteheath Medical Centre Your Health Partnership, Mace Street Clinic Cape Hill Medical Centre Oakeswell Health Centre Stone Cross Medical Centre Norvic Family Practice, Victoria Health Centre Norvic Family Practice, Norman Road Surgery Swanpool Medical Centre Black Country Family Practice Dr P V Gudi & Dr V S Gudi, Hill Top Surgery The Practice Old Hill Oldbury Health Centre Bearwood Road Surgery Dr Pal and Dr Jemahl, Newton Surgery Dr S Bhaumik & Dr S A Ahmed, Jubilee Health Centre Crankhall Lane Medical Centre Sundial Surgery Portway Family Practice Church View Surgery Hawes Lane Surgery New Street Surgery Linkway Medical Practice Central Clinic Dartmouth Medical Centre St Paul's Partnership, St Paul's Surgery Hawthorns Medical Centre Bearwood Medical Centre Haden Vale Medical Practice West Bromwich Partnerships for Health, Oakwood Health Centre The Victoria Surgery Sarephed Medical Centre Glebefields Surgery Great Bridge Partnerships for Health, Slater Street Surgery Great Bridge Partnerships for Health, Cordley Street Surgery Great Bridge Partnerships for Health, Yew Tree Surgery Walford Street Surgery Dr Arora's Practice Causeway Green Road Surgery Park House Surgery St Paul's Partnership – Lyng Medical Dr Haque's Practice Dr Bhadauria, Jubilee Health Centre Cambridge Street Surgery Dr Manivasagam, Clifton Medical Centre Dr Manivasagam, Victoria Health Centre Lodge Road Surgery Dog Kennel Lane Surgery St Paul's Partners Warley Road Surgery The Spires Health Centre Dr Hanna, Hill Top Medical Centre Dr Dewan's Practice Rood End Medical Centre Great Bridge Health Centre Lyndon Health Centre Everyone Health would like to contact you for eligibility purposes by phone and/or email, please check the relevant boxes. I consent to be contacted by: * Email Phone Post Submit Contact Us & Support Everyone Health2 Watling DriveSketchley MeadowsHinckleyLeicestershireLE10 3EY 0333 005 0095 or Text QUIT to 60777
