Smoking Cessation Clinical Pathway - Queensland Health Page 3
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2
3URN:
Family name:
Smoking Cessation
Given name(s):
Clinical Pathway
Address:
Facility:
Date of birth:
Sex:
M
F
I
.........................................................................................................
REFERRAL TO QUITLINE
The Quitline (13 7848) is a FREE telephone counselling service to assist Queenslanders to quit smoking.
Encourage a future quit attempt; advise your patient “The best thing you can do for your health is to stop smoking. When you’re ready,
phone Quitline 13 QUIT (7848), or talk to your doctor or pharmacist”.
Clinicians can refer patients to the service by:
1. Completing this form and fax / email to Quitline. Fax: 3259 8217. Email: 13QUIT@health.qld.gov.au
2. Online and faxback referral forms:
Quit because you can booklets are available in bulk for your service by contacting Quitline 13 QUIT on 13 7848.
Referring Health Professional name: ...................................................................................................................................................................
Profession:
General practitioner
Dentist
Pharmacist
Nurse
Mental health worker
Aboriginal health worker
Other (please specify) …………………………………………………………………………
Is the patient of Aboriginal or Torres Strait Islander origin?
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Aboriginal AND Torres Strait Islander
Would the patient like to speak with a Quitline Aboriginal and/or Torres Strait Islander staff member:
Yes
No
What is the best time and day for Quitline to call the patient? Ask whether the patient wants to be contacted as an inpatient or when
they leave hospital.
Inpatient
Outpatient: expected discharge date
/
/
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
7am-9am
9am-12pm
12pm-5pm
5pm-8.30pm
8.30pm-10pm
If patient does not want Quitline to leave a message, please indicate here
Patient Email: ......................................................................................................Preferred phone: .....................................................................................
GP FOLLOW UP
1. This page can be given to the patient on discharge to take to their GP to complete the GP referral.
2. If patient referred to Quitline and GP details provided on this form, Quitline will notify patient’s GP of contact.
3. Document smoking status, treatment and referrals in discharge summary.
GP name: ...............................................................................................................................................................................................................
GP Practice: .................................................................................................................................................................................................................
Suburb: ..................................................................................................................................................................................................................
HEALTH PROFESSIONAL CONSENT
I confirm that this patient/client consents to receiving a call from the Quitline.
_______________________________
/
/
Health Professional Signature
Date
Privacy Warning: The information contained in this fax/email message is intended for a patients’s GP / Quitline Staff only. If you are not the intended recipient
you must not copy, distribute, take any action reliant on, or disclose ant details of the information in this fax/email to any other person or organisation.
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