Raukura Hauora o Tainui - Smoking Cessation Survey

GO INTO THE DRAW TO WIN A $50 Pak'nSave gift card!

To support our whānau who are striving to quit smoking, we are reaching out with an awesome promotion for World Smokefree Day 31st May 2020 - all you have to do is complete this short survey before 19/06/2020, and you will go in the draw to win a $50 Pak'nSave gift card! (*T&C's apply)

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* 1. Please complete the following contact information below:

Full Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Contact Number

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* 2. Please enter your date of birth:

DD / MM / YYYY

Date

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* 3. Please indicate which status applies to you:

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* 4. If 'Current Smoker', please state approx. intake per day

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* 5. Quitting smoking is hard work, but you don't have to do it alone. Get information and support through the Quitline website – or contact the free Quitline advice service on 0800 778 778 or text 4006

Quitline offer phone, online and text support and can refer to a face-to-face support service

Medicines like nicotine replacement therapy can make it easier for you to stop smoking.

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* 6. If you are trying to quit smoking, there are a number of ways you can receive Smoking Cessation support. Please indicate below which option(s) appeal to you:

Referral to receive Smoking Cessation support

Prescribed Smoking Cessation medication

Motivation/Lifestyle support

I decline to receive any quit smoking support

The above options are not applicable to me

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* 7. Did you know?
Every hour, day, week, month and year that you go without smoking, your health will improve.

You will feel immediate benefits when you quit as your body starts to repair itself. Quitting at any age is beneficial and not only increases life expectancy, it also improves quality of life.

Yes

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* 8. Thank you for taking the time to complete this short survey.
Terms and Conditions:
As long as you;
- are not a current Raukura Hauora o Tainui employee (or immediately related)
- are 15yrs or older
- are currently a registered patient of one of our Raukura Hauora o Tainui Clinics (Waikato Region)
- reside in NZ and if your are our lucky winner can collect your gift card before 5pm on 19/06/2020
- have completed all survey questions correctly,
your name will now be placed into the draw to win a $50 Pak'nSav gift card (one entry per person).
GOOD LUCK!

If you have indicated during the survey that support to quit smoking is required, please advise what time of the day (morning/afternoon) is best for us to contact you: