Please complete the form below and a member of the Help Me Quit contact centre team will call your patient/client within 48 hours.
NB: fields marked * are mandatory
Client / patient details:
Consent for the Help Me Quit contact centre team to contact your patient/client:
Address Line 1*:
Address Line 2:
Address Line 3:
Primary contact number*:
Secondary contact number:
Consent to be contacted by text:
Preferred time to be contacted*:
Special instruction (e.g. hearing impairment):
Select your Health BoardAbertawe Bro MorgannwgAneurin BevanBetsi CadwaladerCardiff and ValeCwm TafHywel DdaPowys Teaching
Select your referral typeGP referralMaternityHospitalPharmacyOptometryDentalPublic Health WalesLocal AuthorityVoluntary SectorOther
Referring organisation (Please add the name of your referring organisation such as GP surgery, maternity team, hospital)*:
Any information we hold about you or your patient / client is protected from use by other individuals and organisations under the Data Protection Act 1998. The information will only be used for the purposes of a member of the Help Me Quit contact centre team contacting you or your patient or client to discuss NHS stop smoking services. You and your patient / client will be notified of any change to the use and purpose of the data.
By completing the above form you are agreeing that you have read and understood the above information relating to the use and storage of any information held about me by Help Me Quit contact centre.