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Healthy Cornwall

Stop Smoking Service

Professional referral form

Please complete all mandatory fields marked *

Referrer details

Referrer first name * 
Referrer last name * 
Referrer job title 
Work base * 
Email address 
Telephone number 
Address line 1 
Address line 2 
Address line 3 
Town 
Postcode 
Comments/notes 

Patient details

First name *
Last name *
Gender *

Address lines 1 *
Address lines 2 
Address lines 3 
Address town *
Postcode *
Date of birth *
Home telephone 
Mobile 
Work telephone 
Email address 
GP Surgery *
What support is required *
Other type of support 
Has the patient had a health check? *

Is this referral as a result of a health check? *

NHS number (if available) 
Hospital number (if available) 

Pregnancy Details

Is the patient pregnant? 

Midwife name 
Midwife base 
Midwife phone 
Midwife email 
Due date 
Hospital number 

Disability Details

Does the patient have a disability? *

Type of disability 
Other disability 

Patient data consent

Consent to all 
Consent to ring 
Consent to leave message 
Consent to text 
Consent to follow up contact *

Consent to GP contact *

As a health record this form will be retained in line with the NHS Retention and Destruction Schedule. By submitting this form the patient consents to us holding this information. *

Statement of consent for patients:

I agree that the information I provide Healthy Cornwall will be stored securely and only seen by staff members dealing with my referral. Only for legal reasons will my personal information be shared i.e. safeguarding concerns.

I understand that this information will be used for the purpose of providing a service. I also understand that anonymised information gained from these services may be used for statistical purposes.

I understand that I may withdraw consent to share information at any time, this may restrict or prevent a service being able to be offered to me.

I understand that I have the right to restrict what information may be shared and with whom, but this may affect the provision of services to me.

I understand that my information will be held securely on paper and/or on a computer in accordance with the Data Protection Act 1998.

I confirm that the client/representative has read/ been read the above statement and has made clear their wish to consent or not. Consent was given: *
Other method of consent 

Please state to patient:

I have made clear that obtainment of personal information is necessary to access our services and we require consent to do so. More information on what we do with this data, their rights to withdraw the data and how long we keep it for can be found on our Privacy Notice which can be found on the Healthy Cornwall website.

Additional information

Notes