Quit smoking Survey

Quit smoking

There are only a few steps to get started.

    Choose your Location

    What is your date of birth?

    Have you ever used medicines to stop smoking?

    Tell us more

    How long have you been smoking?

    How many cigarettes do you smoke each day?

    How soon do you smoke your first cigarette after waking?

    Do you have any of these conditions?

    Tell us more

    Are you allergic to any medicine?

    Please list your drug allergies and what happens when you use that drug.

    Please list any medications you are taking and any other medical conditions you have.

    Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

    Anything else you would like us to know?

    How would you like to pay?

    upload emirates insurance details (if available)

    Billing and delivery details

    Google Map: (Please Share your Google Map Link)
    Delivery Location
    Neighborhood/Area:
    Street Name/No:
    Address Details:

    Personal Details

    Title:
    First Name: Last Name:
    Mobile Number: E-mail:

    Confirm Request and Agree to Terms