Make a Smokefree Homes pledge

I/We pledge to make our home and car completely Smokefree at all times... *

Yes

Today's date *

Is your home already Smokefree? *

Yes No

I/We would like a free fire safety check and free fire alarm and agree to my name, address and tel number being passed on to South Yorkshire Fire And Rescue Service Solely for this purpose... *

Yes No

I/We would like to be referred to the NHS Rotherham Stop Smoking Services... *

Yes No

Title

Name *

Address *

Address line 1

Address line 2

Town

Region

Country

Postcode

Tel

Number of Children Living at this address *

Rotherham Smokefree Homes Services may contact for your feedback about the service, Please tick here if you do not want be contacted.

All fields marked with a * are mandatory. Some or all details in this form may need to be shared with other parts of the NHS. No information will be passed to organisations outside the NHS. The information in this form is not transmitted securely across the internet.

Make a Smokefree Homes pledge

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