Lok Sin Tong Smoking Cessation Program In Workplace | Community Pharmacy: 1-Week NRT Sampling and Pharmacist Counselling Service (Free of charge) Online Registratin
Lok Sin Tong Smoking Cessation Program in Workplace offers 1 week Nicotine Replacement Therapy (NRT) sampling to eligible smokers to promote quit and easy attempts.

This short questionnaire is a registration form of the smoking cessation program (1-Week NRT Sampling).
All the personal information collected are confidential and would only be used for record, assessment and follow-up purposes.

You can contact us for any enquiry via:
Prince Edward - Lok Sin Tong Mr. & Mrs. Lee Yin Yee Community Pharmacy
Tel:  6155 4928（WhatsApp: https://wa.me/85261554928）/ 2338 3718
Address: Flat A, 1211-15, 12/F, Pioneer centre,750 Nathan Road, Prince Edward, Kowloon

Kowloon City - Lok Sin Tong Community Pharmacy
Tel:  9723 3717（WhatsApp: https://wa.me/85297233717）/ 2361 1308
Address: 1/F, Luxe Metro, 50 Junction Road, Kowloon City

Opening hours:
Monday to Friday: 09:00 - 14:00, 15:00 - 18:30
Saturday: 09:00 - 18:30
Sunday and Public Holidays: Closed

如需中文版本，請見:
https://docs.google.com/forms/d/e/1FAIpQLSeagZxVMKyn9D1PoYt-butxtsYWZ7gGXOlBt6rqgAnVsxTeJg/viewform
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1 week NRT Usage Assessment
1. Name (Full name as in your HKID) (e.g. Chan Tai Man) *
2. Phone number (Please ensure the number is correct) *
3. Gender *
4. Age *
5. HKID number (First 4 digits) (e.g. A123) *
6. Are you currently be employed? *
7. Number of cigarettes smoked per day (pieces) *
8. Age 18 or above? *
9. Are you pregnant or breastfeeding? *
10. Do you have any recent stroke, transient ischemic attack, acute myocardial infarction, severe angina, serious cardiac arrhythmia in the past 2 weeks *
11. Do you have any history of allergy to NRT? *
12. Please select the pharmacy to collect the NRT sampling   *
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