Northumberland County Council
BETA
Stop Smoking Referral Form
Patient Details
Patient Name *
Date of Referral *
Please enter in the following format dd/mm/yyyy
NHS Number
Date of Birth *
Please enter in the following format dd/mm/yyyy
Address *
Postcode *
Telephone
Please supply details for at least one contact method from telephone, mobile or email
Mobile
Please supply details for at least one contact method from telephone, mobile or email
Email
Please supply details for at least one contact method from telephone, mobile or email
GP Details
GP Name
GP Telephone
GP Practice *
Referral Details
Referred By *
Telephone *
Dept. or Ward or Site *
Referral Type *
-Please Select-
Client (Community Organisation)
Member of Staff
Other
Patient (CNTW)
Patient (NHCT)
Patient (PCN)
Pathway ( if applicable )
-Please Select-
Lung screening
NHS Staff
On discharge from hospital
Other
Pregnancy partner or family member
Pregnancy preferred service
Severe Mental Illness (SMI) registered HealthCheck patient
SMI partner or family member
Reason for Referral *
Has patient consented to referral? *
-Please Select-
NO
YES
Has patient consented to telephone or text contact? *
-Please Select-
NO
YES
If yes: Can a voicemail be left? *
-Please Select-
NO
YES