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Ngā Taura Tūhono - The Whanganui Stop Smoking Service
Fill in the below to send a referral to your local quit coach, and embark on your Smokefree journey!
*
1.
Current smoker? (Tobacco/ cigarettes)
(Required.)
Yes
No
*
2.
Current Vaper?
(Required.)
Yes
No
*
3.
Do you consent to this referral?
(Required.)
Yes
No
*
4.
First & Last Name
(Required.)
5.
Date of Birth
*
6.
Mobile Phone Number
(Required.)
7.
Ethnicity
NZ European
Māori
Pasific Peoples
MELAA (Middle Eastern, Latin American, African)
Asian
Other
8.
Email address or alternate phone number?
9.
General Practice? (Doctors)
10.
Gender?
Female
Male
Prefer not to say
Other (please specify)
*
11.
How were you referred to us?
(Required.)
12.
Any additional comments or information?
Current Progress,
0 of 12 answered
