Grange Street Surgery
2 Grange Street, St Albans, Herts AL3 5NF

Wifi Sign Up Form

Please complete this form accurately so we can keep your medical records up to date.

 Full Name
 Date of birth
 Home number
 Mobile number
 Email address
 Smoking status
 If you're a current smoker, how many cigarettes do you smoke a day?
 If you're an ex smoker, when did you quit?
 How many units of alcohol do you drink a week?