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Health Promotion Service Cornwall and Isles of Scilly

Stop Smoking Service

Professional referral form

Please complete all mandatory fields marked *

Referrer details

Referrer first name * 
Referrer last name * 
Referrer job title 
Work base * 
Email address 
Telephone number 
Address line 1 
Address line 2 
Address line 3 

Patient details

First name *
Last name *
Gender *

Address lines 1 *
Address lines 2 
Address lines 3 
Address town *
Postcode *
Date of birth *
Home telephone 
Work telephone 
Email address 
GP Surgery *
What support is required *
Other type of support 
Has the patient had a health check? *

Is this referral as a result of a health check? *

NHS number (if available) 
Hospital number (if available) 

Patient data consent

Consent to all 
Consent to ring 
Consent to leave message 
Consent to text 
Consent to follow up contact *

Consent to GP contact *

As a health record this form will be retained in line with the NHS Retention and Destruction Schedule. By submitting this form the patient consents to us holding this information. *

Pregnancy Details

Is the patient pregnant? 

Midwife name 
Midwife base 
Midwife phone 
Midwife email 
Due date 
Hospital number 

Disability Details

Does the patient have a disability? *

Type of disability 
Other disability 

Additional information