Contact Information

Information required for us to contact you to process your first (£25) Smokefree Hampshire voucher.

Device / Liquid Preferences

Answering these questions will mean we can make recommendations more accurately.

  • Contact Info
  • Preferences
  • Additional notes


Full Name

Date of Birth

Phone Number

Email address

Address (First line and postcode REQUIRED)

Preferred Contact Time

So that we can ensure the voucher is claimed by the right person, please upload a clear picture of a valid form of Photo-ID. (Eg. Driving License, Passport, or CitizenCard etc)

- Upload your picture here -

Max. size: 2.0 MB

Smoking Habits

What do you smoke?

How much do you smoke on an average day?(Eg. '20 a day' or 'A few in the week and lots at the weekend')

Vaping Preferences

Are there any styles that you have seen/used that you would prefer?

Are there any features that you would prefer to have?

Flavour Preferences

Nicotine Preference

Please use this box for any additional information for us to see.

Additional Information