Stop Smoking Professional Referral - Fitter Futures Warwickshire

When referring to the stop smoking service you will achieve QOF SMOk004 & SMOk005

Find your NHS number here https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

Stop Smoking – Professional Referral

Patient’s Name

Patient's Name

First

Last

Patient’s Date of Birth (age 12 or over)

Patient’s Gender

Male

Female

Other

Patient’s NHS Number

Does Your Patient Require an Interpreter

Yes

If ‘Yes’, Please State Which Language

Patient’s Contact Number

Patient’s Email

Patient’s Address

Patient's Address

City

County

Post Code

Are You Referring From – GP or Hospital? Are You Referring From – GP or Hospital?

Referring Hospital Referring Hospital

Discharge Date (Hospital Only)

Name of Organisation

Name of Referrer

First

Last

Referrer’s Email

Additional Notes

Data Consent

I confirm I have consent from the named person to upload their personal information.

Contact Consent

I confirm I have consent from the named person for them to be contacted by Everyone Health. Contact will be made for follow-ups on treatments and outcome data via phone call, text, email or post.

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