Get the free NSW Quitline Referral Form - cancerinstituteorgau - cancerinstitute org

NSW Quit line Referral Form Fax the completed form to: 02 9698 2740 (If you receive this fax by mistake, please relax to above number) Client/patient details Given Names: Surname: Sex: Date of birth:(Optional)

How to fill out nsw quitline referral form

How to fill out NSW Quitline Referral Form:

1. Start by obtaining the NSW Quitline Referral Form. You can download it from the official website of NSW Quitline or request a physical copy from a healthcare professional or Quitline representative.
2. Provide your personal information in the designated sections of the form. This includes your full name, address, contact number, and date of birth. Make sure to write legibly and accurately.
3. Indicate whether you prefer to receive support in English or another language by ticking the appropriate box.
4. Specify your preferred method of contact, such as phone, email, or text message.
5. Tick the appropriate checkboxes to indicate which tobacco product(s) you currently use or have used in the past. This can include cigarettes, cigars, pipes, e-cigarettes, or smokeless tobacco.
6. Answer the question regarding your motivation to quit. Choose the option that best describes your reasons for wanting to quit using tobacco products.
7. Indicate if you have made a previous quit attempt and specify the method(s) you used.
8. If you have received any previous support or assistance from NSW Quitline or any other quit smoking service, mention it in the relevant section.
9. If you are currently using any nicotine replacement therapy (NRT) or prescription medication to support your quit attempt, provide the details in the specified field.
10. Sign and date the form to validate your submission.
11. If you have any additional comments or information that you would like to include, write them in the corresponding section.
12. Keep a copy of the completed form for your records.
13. Send the filled-out form to the specified address or submit it to your healthcare professional or Quitline representative.

Who needs NSW Quitline Referral Form:

1. Individuals who are seeking support and guidance to quit smoking or using any other tobacco products.
2. Anyone who resides in New South Wales, Australia, and is looking for assistance from the NSW Quitline program.
3. People who have access to healthcare professionals or Quitline representatives who can provide them with the referral form.

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What is nsw quitline referral form?

The NSW Quitline referral form is a document used to refer individuals to Quitline for support with quitting smoking.

Who is required to file nsw quitline referral form?

Healthcare professionals, social workers, and other professionals working with individuals looking to quit smoking are required to file the NSW Quitline referral form.

How to fill out nsw quitline referral form?

To fill out the NSW Quitline referral form, one must provide the individual's contact information, smoking history, reason for wanting to quit, and any relevant medical information.

What is the purpose of nsw quitline referral form?

The purpose of the NSW Quitline referral form is to connect individuals with resources and support to help them quit smoking.

What information must be reported on nsw quitline referral form?

Information such as contact details, smoking history, reason for quitting, and relevant medical information must be reported on the NSW Quitline referral form.