Referral Form

Consent Statement : "Any personal information you provide will be held in accordance with the General Data Protection Regulation (EU) 2016/679 and used for processing your attendance on the programme. We will share your data with Brio Wellbeing, Cheshire West and Chester Council (commissioner of the service) and your Healthcare Professional. Are you happy to proceed?"

Before submitting this form, please check if you or a person you are referring is eligible for Go Smoke Free service. Our programme is designed for current tobacco smokers aged 12+ who are Cheshire West residents. We cannot accept referrals for anyone who has already stopped smoking and/ or interested in stopping vaping.

Consent to record information *

Select an option

Yes

No

Lastname *

Firstname *

NHS No

GP registered *

Select an option

Unregistered

Registered

GP Details *

Consider themselves disabled

Select an option

Yes

No

DOB *

Gender *

Long Term Condition(s)

Notes

Correspondence Methods

Address *

Letter allowed? *

Select an option

Yes

No

Postcode *

Please enter a valid UK postcode.

Tel *

Mobile

SMS allowed?

Select an option

Yes

No

Email

Email allowed

Select an option

Yes

No

General Notes

Details of Referrer

Name

Job Title

Organisation Name *

Phone Number

Email Address *

Stop Smoking Aids Supplied (please include quantities)

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