Get the free Stop Smoking Referral Form

Stop Smoking Referral Form Further information on your local QUIT services can be found on www.quit.ie or call 1800 201 203 REFERRING TO: Quit Midwest Health Promotion & Improvement, HSE Science Offices, Francis

How to fill out stop smoking referral form

How to fill out stop smoking referral form

1. Obtain a stop smoking referral form from a healthcare provider or clinic.
2. Fill out your personal information including name, contact details, and date of birth.
3. Provide details about your smoking history such as number of cigarettes smoked per day and duration of smoking.
4. Specify your reason for seeking help to quit smoking and any other relevant health information.
5. Sign and date the form to confirm your consent for referral and treatment.

Who needs stop smoking referral form?

1. Individuals who are looking to quit smoking and seeking help and support to do so.
2. Healthcare providers who want to refer patients to smoking cessation programs or services.

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What is stop smoking referral form?

Stop smoking referral form is a document used to refer individuals who want to quit smoking to appropriate smoking cessation programs or resources.

Who is required to file stop smoking referral form?

Healthcare professionals, employers, or any individual concerned about someone's smoking habit may be required to file a stop smoking referral form.

How to fill out stop smoking referral form?

To fill out a stop smoking referral form, you need to provide the personal information of the individual being referred, their smoking history, and any relevant medical information.

What is the purpose of stop smoking referral form?

The purpose of stop smoking referral form is to help individuals quit smoking by connecting them with support services and resources.

What information must be reported on stop smoking referral form?

Information such as the individual's name, contact information, smoking habits, medical history, and reasons for wanting to quit smoking must be reported on the stop smoking referral form.