Professional Referral Form

Please complete the form below and a member of the Help Me Quit contact centre team will call your patient/client within 72 hours.

Please note, prescription only medications such as Zyban and Champix are not currently available.

NB: fields marked * are mandatory

Client / patient details:

If your client/patient is currently in hospital, please provide:

Hospital*:
Ward*:
Expected duration of stay/discharge date*:

Title*:

Forename*:

Surname*:

Address Line 1*:

Address Line 2:

Post Code*:

Preferred Language*:

Consent to be contacted by text:

YESNO

Contact Number*

Preferred time to be contacted*:

Special Instruction (e.g. Hearing Impairment):

Referrers details:

Forename*:

Surname*:

Health Board*:

Referral Type*:

Referring organisation (Please add the name of your referring organisation such as GP surgery, maternity team, hospital)*: