For use by health professionals to refer patients to the Quitline.
Mandatory fields are marked with an *
Patient Information - CONFIDENTIAL
First Name*
Last Name*
Phone (one of)* - Home
Mobile
Preferred Contact Number*
Home
Mobile
What is the best time for the Quitline to call?*
--None--
AM
PM
Evening
Does your patient identify as Aboriginal or Torres Strait Islander?*
--None--
Yes
No
Unknown
Referrer Details
First Name*
Last Name*
Organisation*
Email*
Phone*
Please Note:
By submitting this referral you acknowledge that your patient has consented to this information being disclosed.
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