Smoking referral form

Stop smoking service referral form

If you would like to access stop smoking support, please complete the form below and we will contact you.

Please note that we can only take referrals from residents of Hartlepool Borough Council and Stockton-on-Tees Borough Council.

Disclaimer(Required)

I understand that by completing this form I give permission to the NHS Stop Smoking Service to store my information in order to contact me to offer me support to become a non smoker

First name(Required)

Last name(Required)

Date of birth(Required)

What is your sex?(Required)

Please state(Required)

Contact number(Required)

Address(Required)

Address Line 1 Address Line 2 City County Postcode

Can we leave you a voicemail?(Required)

Preferred contact time(Required)

9am to 12 midday

12 to 2pm

2pm to 4pm

No preference

Can we send you a text message(Required)

Can we write to you if we are unable to contact you by phone?(Required)

Healthcare professionals

If you are a health professional completing this referral form, please leave your details here

Name

Role

Organisation

Special instruction's

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Stop smoking service referral form

Healthcare professionals