SEARCH
Health and Community Services >
Quitline Referral
Quitline Referral
All fields mark with
*
are compulsory. fields marked with
*
are conditionally 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)
*
Home:
*
Work:
*
Mobile:
*
Date of Birth:
(dd/mm/yyyy)
Aboriginal or Torres Strait Islander origin?
Yes
No
Interpreter?
Yes
No
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
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
*
Organisational Setting:
General Practice
Health Care Service
Pharmacy
ATSI Worker
Hospital
Dental Practice
Other
Address:
Postal Code:
*
Contact Phone:
*
Email:
*
Type of referral:
Youth (15-29 years)
Disadvantaged (health care card holder)
Pregnancy
Pregnancy-partner/family
Culturally & Linguistically Diverse (CALD)
General/Other
For any questions, please phone the Quitline on 8291 4282.
