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Welcome to My Quit Suffolk!

Decided to quit smoking but feel you can do it without the support of a trained advisor? Order our self-help kit to maximize your chances of succe

ss! Included in our kit are a variety of tools and aids including our self-help manual, wall-chart and most importantly, access to our App – giving you everything you need to quit smoking without leaving the house!

Use the order form below, and we’ll send your pack to you.

My Quit

Please fill in the details below so we can get your kit out to you (within 5 working days)

F ull name *

Address *

Postcode *

Date of Birth *

Gender *

Mobile phone *

Email address *

Occupation *

How many cigarettes do you smoke per day? *

Are you pregnant? *

Do you have any existing medial conditions? *

Would you like a FREE† Nicotine Replacement Therapy (NRT) voucher, which you can redeem at any pharmacy?

Please select a nicotine patch *

In addition to a nicotine patch, it’s proven that a secondary product significantly increases your chances of quitting. If you’d like a secondary product, please select from the list below *

Do you pay for your prescriptions? *

Please select one of the following: *

By ticking this box, I confirm that all of the above information is correct and up to date and that I consent to Live Well Suffolk contacting me for follow-up purposes (in-line with the data protection act). I understand that my details will be stored for medical purposes including sharing information with my GP.

If issued with Nicotine Replacement Therapy (NRT), I agree to read the patient information before using any of the products and seek advice from a pharmacist or GP if I have any product concerns.

†NRT is free if you don’t currently pay for prescriptions, otherwise NRT will be available at prescription price (per product)

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