Sunderland-Washington Smoking Cessation Referral Form Who is making this referral? Patient Professional Link Worker Self ReferralFull NameAs shown on medical recordWould prefer to be known by / What name do you prefer to be called? OptionalDate of Birth Day Month Year Are you registered with a GP in Sunderland? Yes No To use this service you need to be registered with a GP. Click here to find a GP Practice in your area.Are you homeless? Yes No Address Street Address Address Line 2 City Postcode Name of GP registeredPlease select..The Stephenson Medical Practice (Dr Stephenson and Partners)New Washington Medical GroupConcord Medical CentreI J Healthcare (Harraton Surgery)Rickleton Medical CentreMonument Surgeries (Barmston and Galleries)Patient Contact numberEmail Optional Reason for ReferralPlease Select..Smoking CessationWhere did you hear about this service? OptionalPlease selectText from PracticeSunderland Health and Wellbeing HubSocial Media e.g. FacebookYour GP Practice WebsiteOtherAdditional Information: Please provide extra information regarding the referralProfessional ReferralDo you have the patient's consent to make this referral? Yes No You must have patient consent to proceed Name of ProfessionalService NameTelephone of ProfessionalEmail of Professional Any Identifiable Risks ? Yes No RisksFull Name of PatientPatient's Date of Birth Day Month Year Is the Patient Homeless? Yes No Address Street Address Address Line 2 City Postcode Name of GP registeredPlease select..The Stephenson Medical Practice (Dr Stephenson and Partners)New Washington Medical GroupConcord Medical CentreI J Healthcare (Harraton Surgery)Rickleton Medical CentreMonument Surgeries (Barmston and Galleries)Patient's Contact NumberPatient's Email Optional Reason for ReferralPlease Select..Smoking CessationAdditional Information: Please provide extra information regarding the referral OptionalLink worker (Outreach)Do you have the patient's consent to make this referral? Yes No You must have patient consent to proceed Name of Link workerEvent / Outreach venueFull Name of PatientPatient's Date of Birth Day Month Year Is the Patient Homeless? Yes No Patient's Address Street Address Address Line 2 City Postcode Name of GP registeredPlease select..The Stephenson Medical Practice (Dr Stephenson and Partners)New Washington Medical GroupConcord Medical CentreI J Healthcare (Harraton Surgery)Rickleton Medical CentreMonument Surgeries (Barmston and Galleries)Patient's Contact NumberPatient's Email Optional Reason for ReferralPlease Select..Smoking CessationAdditional Information: Please provide extra information regarding the referralComments OptionalThis field is for validation purposes and should be left unchanged.
