• Smoking Cessation Consultation e-form

    Smoking Cessation Consultation e-form

  • This is a cessation education service for those who wish to quit smoking.  

    UPDATED SMOKING CESSATION GUIDELINES

    Those NOT eligible are users of ongoing or repeat NRT or vapers.  Refer to QUITLINE

     

  • Pharmacy Details

  • Claimant Number*
  • Claimant Number*

  • Patient Information

  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year

  • Informed consent | Healthify

  • Consultation Data

  • Smoking Status*
  • Health Conditions
  • Completed Actions*

  • Pharmacist Declaration

  • Consultation Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  •  
  • Should be Empty: