Home

Quit Smoking

Health Professional Referral to Quitline

Options for referring clients to the Quitline 13 QUIT:

Complete -

Indicates Mandatory Fields

Quitline is a confidential service, all information provided remains confidential.

Client details

Name:
Sex:	Male Female
Date of Birth: (dd/mm/yyyy)
Postcode:
Aboriginal and Torres Strait Islander origin?
Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander No
Australian South Sea Islander origin?
Yes No
Contact phone number:	(please provide the best phone number for the contact at the time of the requested call)
Email address:
Preferred contact time: (tick all that apply)
7am - 9am 9am - 12pm 12pm - 5pm 5pm-8.30pm 8.30pm - 10pm
Preferred day of the week: (tick all that apply)
Mon Tues Wed Thur Fri Sat Sun
Is it ok to leave a message?
Yes No
Contact requirements
Translating and Interpreting Service (please specify language ) National Relay Service Female staff member preferred Male staff member preferred Aboriginal and/or Torres Strait Islander staff member preferred Other (please specify )
Health information (please select all applicable)
Diabetes Type 1 Diabetes Type 2 Heart Disease Respiratory Disease Pregnant/breastfeeding Epilepsy Anxiety Depression
Notes

Health Professional details

Name:
Health Practice/Organisation:
Profession:
Professional setting:
Address:
Postcode:
Phone number:
Email address: