Quitline Referral

All fields marked with * are compulsory.

Client Details:

Title:	Mr Mrs Ms
* Name:
Address:
Postal Code:
Contact Phone Number (please provide the best phone number for contact at the time of the requested call)
* Contact No:
Interpreter?	YesNo If yes, language:
Time for first call (allow up to 30 minutes):
Day:	Monday Tuseday Wedneday Thursday Friday Saturday
* Date:	(dd/mm/yyyy)
* Best Time to Call:	8:30am-1pm Mon to Fri 1pm-5pm Mon to Fri 5pm-8pm Mon to Fri 2pm-5pm Sat
In compliance with the 2001 Privacy Bill, Quit SA is required to ask the following questions:
Can Quitline send reports to your referring health care provider informing of your quitting progress?	YesNo
Referring professional details:
* Name:
Organisation:
* Profession:	GP Nurse/Midwife Mental Health Worker Aboriginal Health Service Worker Drug & Alcohol worker Community Services Worker Dentist Pharmacist Other
Address:
Postal Code:
* Contact Phone or Email:
	Once you click submit you will be presented with the option to save or open a pdf version of this form for your patient records
For any questions, please phone the Quitline on 8291 4282.