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Online Booking Form of Christian Family Service Centre Smoking Cessation Services (Free, Quick, Convenient)
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* Indicates required question
This short questionnaire helps to assess your current smoking dependence status.
You may also make an online booking.
All the personal information are strictly confidential and would only be used for record, assessment and follow-up purposes.
Please call 31021484
for any inquiry.
Name
*
Your answer
Contact Number (Please make sure the number is correct)
*
Your answer
Cigarette Consumption Modes
*
Traditional Cigarettes
Heated Tobacco Products
Electronic Cigarettes
Waterpipe Tobacco
Required
Main reason(s) for quit smoking? (Check ALL that apply)
*
Prove my ability to quit smoking
Health Concern (Yourself or Others)
Family
Money Saving
Others
Required
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