Question 1 of 12
Are you trying to quit smoking?
Question 2 of 12
Have you tried to quit before?
Question 3 of 12
Have you tried any medications before to quit smoking?
Question 4 of 12
Are you looking for any specific treatment to help quit smoking?
Question 7 of 12
Do you have any health conditions?
Question 8 of 12
Do you have any mental health conditions?
Question 9 of 12
Are you currently taking any medications ?
Question 10 of 12
Do you have any allergies?
Question 5 of 12
How many cigarettes do you smoke daily?
Question 6 of 12
How many years have you smoked for?
Question 11 of 12
Is there any further information you would like to provide?
Question 12 of 12
Would you like to have a video or telephone consultation?