Referral : Welcome

Thank you for taking the first step towards a healthier, smoke-free future. As part of our initiative to support you in quitting smoking, we’re excited to offer you a free vape kit to help you make the switch. This program is designed to assist you in reducing or quitting smoking altogether by providing a safer alternative.
Please take a moment to complete this form so we can better understand your needs and support your journey! On completion, we'll contact you to arrange your tailored Quit Kit delivery and talk you through how to use the product and answer any additional questions you might have.

Please fix the following issues before continuing:

Consent and Agreement: By participating in the Swap to Stop Scheme, I understand and agree to the following:

The information provided in this form will be used to support my journey to quit smoking and to issue a vape kit as part of the scheme.
My data will be recorded and stored securely in compliance with GDPR regulations and will not be shared with unauthorised third parties.
Participation in the scheme requires active engagement, and I agree to provide feedback when requested to help improve the program.
I confirm that I am over 18 years old and currently smoke tobacco products.

Consent to record information *

Yes

Have you ever had a vape kit from us before *

Yes

Firstname *

Lastname *

DOB *

Address *

Letter allowed? *

Yes

Postcode *

Tel *

Mobile

SMS allowed?

Yes

Best time to contact you? *

Morning

Afternoon

Evening

How many cigarettes are you currently smoking per day? *

Where is your nearest pick up point for your quit kit to be delivered? *

Welcome to Cheshire West and Chester's Swap to Stop Scheme!