CHARTFIELD SURGERY

020 8788 3252 - Dial 111 Out of Hours

DO NOT ATTEND THE SURGERY UNLESS INSTRUCTED BY A CLINICIAN. FACE COVERINGS ARE MANDATORY.

PATIENT INFORMATION: PLEASE BE WARY OF COVID-19 VACCINATION SCAMS

SMOKING STATUS

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I understand this form is not for Urgent Care. I am happy for Chartfield to contact me as appropriate and for this information to be entered into my medical record. I am submitting this information for myself or as the authorised proxy of someone else.

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