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Smoking advice service (sas) referral form

Smoking Advice Service (SAS) Referral and Registration
FOR OFFICE USE ONLY
Client ID Number CHP  Aberdeen City  Aberdeenshire  Moray  Name: Referring GP Practice:
MORAY COAST MEDICAL PRACTICE
MUIRTON ROAD
LOSSIEMOUTH


TO BE COMPLETED BY THE DOCTOR

This patient is medically suitable to receive:
Nicotine Replacement Therapy (NRT) Bupropion (Zyban) Smoking Cessation Advice Only (i.e. no pharmacology suitable) The above client has been seen by me today to request smoking cessation support. I have discussed treatment options, reviewed the client’s medical records and would like to request further advice from the SAS. Signed ___________________ Print Name (Doctor):___________________ Date:___________ Please detail any other information which is relevant to the client receiving smoking cessation support and attending sessions e.g. level access or hearing induction loop required. ______________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________
If intensive support is required, please ask the client to complete the reverse side then post to:
Smoking Advice Service, Summerfield House, Eday Road, Aberdeen, AB15 6RE or fax to
01224 558672 . (To avoid duplication, please DO NOT fax and then post orinigal).
TO BE COMPLETED BY THE SMOKING CESSATION ADVISOR
The above client has been seen by a trained smoking cessation advisor. We have discussed
treatment options and the client has been offered additional smoking cessation support.
Following discussion, the preferred treatment option is: Nicotine Replacement Therapy (NRT) Bupropion (Zyban) Smoking Cessation Advice Only Please reassess for the following reason / notes __________________________________ ______________________________________________________________________________________________________________________________________________________ Signed _______________________ Print Name:______________________ Date:___________ Designation:____________________________________________________________________ Give completed, full sheet to client to take back to GP if prescription is required. In other cases, post the completed full sheet back to GP Surgery. Smoking Advice Service (SAS) Referral and Registration
TO BE COMPLETED BY THE CLIENT
EMPLOYMENT STATUS (Please tick one box)
Other ____________________________________________________________________
WHICH OF THE FOLLOWING BEST DESCRIBES YOUR ETHNIC ORIGIN?
(Choose one section from A-F, and then tick one box only within that section)
A White
B Mixed background
C Asian, Asian Scottish D Black, black Scottish
Any other Asian background (please specify)
E Any other ethnic group_______________________
F Do not wish to disclose
Are you currently thinking about having or trying for a baby? Are there any specific times you are unavailable to attend sessions e.g. during working hours? ______________________________________________________________________________ TOBACCO USE AND QUIT ATTEMPTS On average, how many How soon after waking do cigarettes do you usually you usually smoke your first
SMOKING CESSATION SERVICE CONSENT
Please read and complete the following. Please ask if you would like any item to be explained. If you
do not agree to any of the following, you are still entitled to receive treatment.
I am willing for my details to be kept on a confidential database
I agree to be contacted in the future in connection and for anonymised information to be used to assess how the with my smoking (at the end of the programme, and Yes No In order for the service to contact me, I agree to a message being left on my home / mobile (delete as appropriate) answer-phone if necessary. The message will say that the NHS Grampian Smoking Advice Service has tried to contact you. It may also suggest an appointment time and ask you to phone back.
Data Confidentiality and Security
The information provided by you will be held in a secure environment in accordance with The Data Protection Act (1998).
The information will only be used to assess the outcome of this project and no details will be passed on to any organizations who are not involved in the outcome assessment. Client Name:____________________________ Signature: _____________________ Date:___________ Smoking Advice Service, Summerfield House, Eday Road, Aberdeen, AB15 6RE. Tel: 0500 600332, Fax: 01224 558672, email

Source: http://www.moraycoastmedicalpractice.co.uk/website/S32764/files/Smoking_Cessation_Form.pdf

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Patient Details Surname: _______________________________ Initials: ______________ Title: _______________________ First Names: ______________________________________ ID number: ______________________________ Home Tel: ____________________ Work Tel: ____________________ Cell: _________________________ E-mail address: __________________________________________________________________________

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