Smokefree Island

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Professional Referral

Please use the below form to make a patient referral to one of our Smokefree Island stop smoking services.

Whilst many of these fields are optional, we do request you provide your referrer details, so that any clarifications can be made to aid in the correct triaging for the service user.

If you are a member of the public looking to stop smoking and request either telephone or online support, please use the form on our self-referrals page.

    Preferred Time(s) to Call to Arrange the Next Step

    May we leave a message?

    Does the client need to stop smoking in preparation for an operation?

    Has the client been diagnosed with a mental health condition?

    Is the client pregnant?

    Does the client have diabetes?

    Has the client been diagnosed with any of the following long term health conditions?

    Has the client consented to receiving information from the practice / pharmacy on stopping smoking and / or the services available?

    Has the client consented to you sending this form on their behalf?*

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