This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Smoking Cessation – Southampton West PCN by Southampton West Health & Wellbeing Team Who is this referral for? I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "•Aged 18+ •Current smoker •Willing to commit to stopping smoking •Patient registered in Southampton West PCN surgery." Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery NHS number Gender SelectFemale Male Transgender female Transgender male Non-binary Intersex Not specified Not known Other Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. What are the reasons for this referral? Smoking cessation Other: This field is required. Should the service provider be aware of any additional needs? Blind/partially blind Memory problem Hearing loss Housebound Does not speak English Poor mobility Learning and communication needs Physical disability Frail Other: Please share some brief details regarding this referral Tick to confirm that this patient is safe to be seen on their own Are there any known risks to service users or staff in the past? Yes No This field is required. If any known risks, please provide some details below. Where there are identified risks, the team may be in contact to discuss further. We are committed to providing the best support for all patients. Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
