Stop Smoking waiting list (professional referral)

By completing this form, your patient is agreeing to be added to a waiting list for stop smoking support and your patient will be contacted by the new Provider after the 1 July 2026. If you do not wish to be added to a waiting list, please go back to the smoking service webpage to see what other options are available to you.

Stop Smoking – Professional Referral

Patient’s Name

Patient's Name

First

Last

Patient’s Date of Birth

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

Postcode

Is your patient over the age of 12?

Yes, my patient is over the age of 12

Does your patient work, study or live in Warwickshire or are they registered with a Warwickshire GP?

Yes, my patient works, studies or lives or is registered with a GP in Warwickshire

Where are you referring from? Where are you referring from?

Name of Organisation

If you are referring from a Hospital, please state which Hospital you are referring from

Which department are you referring from?

If you are referring from a Hospital, please provide the patient’s discharge date

If you are referring from CWPT, please complete the following two questions

Optional medication (CWPT patients only)

Vape kit issued (CWPT patients only)

Yes

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.

Data Sharing Consent

I confirm I have consent from the named person to upload their personal information and for this to be shared with ICE Creates LTD.

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